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Rodrigues AR, Oliveira A, Vieira T, Assis R, Lume C, Gonçalves-Pereira J, Fernandes SM. A prolonged intensive care unit stay defines a worse long-term prognosis - Insights from the critically ill mortality by age (Cimba) study. Aust Crit Care 2024; 37:734-739. [PMID: 38649316 DOI: 10.1016/j.aucc.2024.03.001] [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: 07/27/2023] [Revised: 01/11/2024] [Accepted: 03/02/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Patients with critical illness often survive the intensive care unit (ICU) at a cost of prolonged length of stay (LOS) and slow recovery. This chronic critically ill disease may lead to long-term poor outcomes, especially in older or frail patients. OBJECTIVES The main goal of this study was to address the characteristics and outcomes of patients with prolonged ICU LOS. Mainly, short- and long-term admissions were compared to identify risk factors for persistent critical illness and to characterise the impact on ICU, hospital, and long-term mortality. METHODS Subanalysis of a retrospective, multicentric, observational study addressing the 2-year outcome of patients admitted to Portuguese ICUs (the Cimba study). Patients were segregated according to an ICU LOS of ≥14 days. RESULTS Data from 37 118 patients were analysed, featuring a median ICU LOS of 4 days (percentile: 25-75 2-9), and a mortality of 16.1% in the ICU, 24.0% in the hospital, and 38.7% after 2 years. A total of 5334 patients (14.4%) had an ICU LOS of ≥14 days (corresponding to 48.9% of all ICU patients/days). Patients with prolonged LOS were more often younger (52.8% vs 46.4%, were ≤65 years of age , p < 0.001), although more severe (Simplified Acute Physiology Score II: 49.1 ± 16.9 vs 41.8 ± 19.5, p < 0.001), and had higher ICU and hospital mortality (18.3% vs 15.7%, and 31.2 vs 22.8%, respectively). Prolonged ICU LOS was linked to an increased risk of dying during the 2-year follow-up (adjusted Cox proportional hazard: 1.65, p < 0.001). CONCLUSION Prolonged LOS is associated with a long-term impact on patient prognosis. More careful planning of care should incorporate these data.
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Affiliation(s)
- Ana Rita Rodrigues
- Clinica Universitária de Medicina Intensiva, FMUL, Lisbon, Portugal; Intensive Care Department, Hospital St(a) Maria, Lisbon, Portugal
| | - André Oliveira
- Intensive Care Unit, Hospital de Vila Franca Xira, EPE, Portugal
| | - Tatiana Vieira
- Intensive Care Department, Hospital de São João, Porto, Portugal
| | - Rui Assis
- Intensive Care Unit, Centro Hospitalar Médio Tejo, Abrantes, Portugal
| | - Catarina Lume
- Intensive Care Unit, Hospital Nélio Mendonça, Funchal, Portugal
| | - João Gonçalves-Pereira
- Clinica Universitária de Medicina Intensiva, FMUL, Lisbon, Portugal; Intensive Care Unit, Hospital de Vila Franca Xira, EPE, Portugal; Grupo Infeção e Desenvolvimento em Sépsis (GIS-ID), Porto, Portugal
| | - Susana M Fernandes
- Clinica Universitária de Medicina Intensiva, FMUL, Lisbon, Portugal; Intensive Care Department, Hospital St(a) Maria, Lisbon, Portugal; Grupo Infeção e Desenvolvimento em Sépsis (GIS-ID), Porto, Portugal.
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2
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Tao J, Seier KP, Chawla S, Tan KS, Wheeler A, Sanzone J, Marasigan-Stone CB, Simondac JSS, Pascual AV, Kostelecky NT, Voigt LP. Impact of Delirium Onset and Duration on Mortality in Patients With Cancer Admitted to the ICU. J Intensive Care Med 2024; 39:900-908. [PMID: 38629453 DOI: 10.1177/08850666241244733] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2024]
Abstract
BACKGROUND Little is known on the effects of delirium onset and duration on outcome in critically ill patients with cancer. OBJECTIVES To determine the impact of delirium onset and duration on intensive care unit (ICU) and hospital mortality and length of stay (LOS) in patients with cancer. METHODS Of the 915 ICU patients admitted in 2018, 371 were included for analysis after excluding for terminal disease, <24-h ICU stay, lack of active cancer and delirium. Delirium was defined as early if onset was within 2 days of ICU admission, late if onset was on day 3 or later, short if duration was 2 days or less, and long if duration was 3 days or longer. Patients were placed into 4 combination groups: early-short, early-long, late-short, and late-long delirium. Multivariate analysis controlling for sex, age, metastatic disease, and predelirium hospital LOS was performed to determine ICU and hospital mortality and LOS. Exploratory analysis of long-term survival was also performed. Restricted cubic splines were performed to confirm the use of 2 days to distinguish between early versus late onset and short versus long duration. RESULTS A total of 32.9% (n = 122) patients had early-short, 39.1% (n = 145) early-long, 16.2% (n = 60) late-short, and 11.9% (n = 44) late-long delirium. Late-long delirium was independently associated with increased ICU (OR 4.45, CI 1.92-10.30; P < .001) and hospital (OR 2.91, CI 1.37-6.19; P = .005) mortality and longer ICU (OR 1.97, CI 1.58-2.47; P < .001) LOS compared to early-short delirium. Early delirium had better overall survival at 18 months than late delirium. Long-term survival further improved when delirium duration was 2 days or less. Prediction heatmaps confirm the use of a 2-day cutoff. CONCLUSION Late delirium, especially with long duration, significantly worsens outcome in ICU patients with cancer and should be considered a harbinger of poor overall condition.
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Affiliation(s)
- Jing Tao
- Department of Anesthesiology & Critical Care Medicine, Critical Care Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kenneth P Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sanjay Chawla
- Department of Anesthesiology & Critical Care Medicine, Critical Care Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amanda Wheeler
- Department of Occupational Therapy, Sacred Heart University, Fairfield, CT, USA
| | - Joanna Sanzone
- Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Analin V Pascual
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natalie T Kostelecky
- Department of Anesthesiology & Critical Care Medicine, Critical Care Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Louis P Voigt
- Department of Anesthesiology & Critical Care Medicine, Critical Care Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
- Department of Medicine, Supportive Care Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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3
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Chen W, Song J, Gong S. Advances in nutritional metabolic therapy to impede the progression of critical illness. Front Nutr 2024; 11:1416910. [PMID: 39036495 PMCID: PMC11259093 DOI: 10.3389/fnut.2024.1416910] [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: 04/13/2024] [Accepted: 06/26/2024] [Indexed: 07/23/2024] Open
Abstract
With the advancement of medical care and the continuous improvement of organ support technologies, some critically ill patients survive the acute phase of their illness but still experience persistent organ dysfunction, necessitating long-term reliance on intensive care and organ support, known as chronic critical illness. Chronic critical illness is characterized by prolonged hospital stays, high mortality rates, and significant resource consumption. Patients with chronic critical illness often suffer from malnutrition, compromised immune function, and poor baseline health, which, combined with factors like shock or trauma, can lead to intestinal mucosal damage. Therefore, effective nutritional intervention for patients with chronic critical illness remains a key research focus. Nutritional therapy has emerged as one of the essential components of the overall treatment strategy for chronic critical illness. This paper aims to provide a comprehensive review of the latest research progress in nutritional support therapy for patients with chronic critical illness.
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Affiliation(s)
- Wenwei Chen
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia Song
- Zhejiang Hospital, Hangzhou, China
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4
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Halacli B, Yildirim M, Kaya EK, Ulusoydan E, Ersoy EO, Topeli A. Chronic critical illness in critically ill COVID-19 patients. Chronic Illn 2024; 20:86-95. [PMID: 36883242 PMCID: PMC9996170 DOI: 10.1177/17423953231161333] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/08/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVES To evaluate the presence of chronic critical illness (CCI) in COVID-19 patients and compare clinical characteristics and prognosis of patients with and without CCI admitted to intensive care unit (ICU). METHODS It was a retrospective, observational study at a university hospital ICU. Patients were accepted as CCI if they had prolonged ICU stay (≥14 days) and got ≥1 score for cardiovascular sequential organ failure assessment (SOFA) score and ≥2 score in other parameters on day 14 of ICU admission which was described as persistent organ dysfunction. RESULTS 131 of 397 (33%) patients met CCI criteria. CCI patients were older (p = 0.003) and frailer (p < 0.001). Their Acute Physiology and Chronic Health Evaluation (APACHE) II and SOFA scores were higher, PaO2/FiO2 ratio was lower (p < 0.001). Requirement of invasive mechanical ventilation (IMV), steroid use, and septic shock on admission were higher in the CCI group (p < 0.001). CCI patients had higher ICU and hospital mortality than other patients (54.2% vs. 19.9% and 55.7% vs. 22.6%, p < 0.001, respectively). Regression analysis revealed that IMV (OR: 8.40, [5.10-13.83], p < 0.001) and PaO2/FiO2 < 150 on admission (OR: 2.25, [1.36-3.71], p = 0.002) were independent predictors for CCI. DISCUSSION One-third of the COVID-19 patients admitted to the ICU were considered as CCI with significantly higher ICU and hospital mortality.
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Affiliation(s)
- Burcin Halacli
- Department of Internal Medicine, Division of Intensive Care Medicine, Hacettepe University, Ankara, Turkey
| | - Mehmet Yildirim
- Department of Internal Medicine, Division of Intensive Care Medicine, Hacettepe University, Ankara, Turkey
| | - Esat Kivanc Kaya
- Department of Internal Medicine, Division of Intensive Care Medicine, Hacettepe University, Ankara, Turkey
| | - Ege Ulusoydan
- Department of Internal Medicine, Hacettepe University, Ankara, Turkey
| | - Ebru Ortac Ersoy
- Department of Internal Medicine, Division of Intensive Care Medicine, Hacettepe University, Ankara, Turkey
| | - Arzu Topeli
- Department of Internal Medicine, Division of Intensive Care Medicine, Hacettepe University, Ankara, Turkey
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Martínez-Camacho MÁ, Jones-Baro RA, Gómez-González A, Lugo-García DS, Astorga PCG, Melo-Villalobos A, Gonzalez-Rodriguez BK, Pérez-Calatayud ÁA. Prolonged intensive care: muscular functional, and nutritional insights from the COVID-19 pandemic. Acute Crit Care 2024; 39:47-60. [PMID: 38303585 PMCID: PMC11002617 DOI: 10.4266/acc.2023.01284] [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: 10/10/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 02/03/2024] Open
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, clinical staff learned how to manage patients enduring extended stays in an intensive care unit (ICU). COVID-19 patients requiring critical care in an ICU face a high risk of experiencing prolonged intensive care (PIC). The use of invasive mechanical ventilation in individuals with severe acute respiratory distress syndrome can cause numerous complications that influence both short-term and long-term morbidity and mortality. Those risks underscore the importance of proactively addressing functional complications. Mitigating secondary complications unrelated to the primary pathology of admission is imperative in minimizing the risk of PIC. Therefore, incorporating strategies to do that into daily ICU practice for both COVID-19 patients and those critically ill from other conditions is significantly important.
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Affiliation(s)
| | - Robert Alexander Jones-Baro
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | - Alberto Gómez-González
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | - Dalia Sahian Lugo-García
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | | | - Andrea Melo-Villalobos
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
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Sánchez-Arguiano MJ, Miñambres E, Cuenca-Fito E, Suberviola B, Burón-Mediavilla FJ, Ballesteros MA. Chronic critical illness after trauma injury: outcomes and experience in a trauma center. Acta Chir Belg 2023; 123:618-624. [PMID: 35881765 DOI: 10.1080/00015458.2022.2106626] [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: 11/04/2021] [Accepted: 07/23/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To determine the prevalence, risk factors and functional results of chronic critical illness (CCI) in polytrauma patients. DESIGN Single-center observational retrospective study. SETTING ICU at a tertiary hospital in Santander, Spain, between 2015 and 2019. PATIENTS Adult trauma patients who survived beyond 48 h after injury. CCI was defined as the need for mechanical ventilation for at least 14 days or tracheostomy for difficult weaning. MEASUREMENTS AND MAIN RESULTS About 62/575 developed CCI. These patients were characterized by higher ISS score [17 (SD 10) vs. 13.8 (SD 8.2); p < 0.001] and higher NISS (26 (SD 11) vs. 19.2 (SD 10.5); p = 0.001). CCI group had greater proportion of hospital-acquired infections (100% vs. 18.1%; p < 0.001), and acute kidney failure (33.9% vs. 22.8% p < 0.001). During the first 24 h of admission, CCI group required in a greater proportion surgical intervention (50% vs. 29%; p = 0.001), and blood products (31.3% vs. 20.5%; p < 0.047). Hospital ward stay was longer in CCI patients [9.5 days (IQR 5-16.9) vs. 43.9 (IQR 30.3-53) p < 0.001]. The CCI mortality was higher (19.5% vs. 8.1%; p = 0.004). Surgical intervention in the first 24 h (OR 2.5 95% CI 1.1-4.1), age (> 55 years) (OR 2.1 95%CI 1.1-4.2), ISS score (OR 1.1 95%CI 1.02-1.3), GCS score (OR 0.8 95%CI 0.4-23.2) and multiple organ failure (OR 9.5 95%CI 3.9-23.2) were predictors of CCI in the multivariate analysis. CONCLUSIONS CCI after severe trauma appears in a considerable proportion of patients. Early identification and implementation of specific interventions could change the evolution of this process.
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Affiliation(s)
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - Elena Cuenca-Fito
- Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | - María A Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
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7
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da Rocha FR, Gonçalves RC, Prestes GDS, Damásio D, Goulart AI, Vieira AADS, Michels M, da Rosa MI, Ritter C, Dal-Pizzol F. Biomarkers of neuropsychiatric dysfunction in intensive care unit survivors: a prospective cohort study. CRITICAL CARE SCIENCE 2023; 35:147-155. [PMID: 37712803 PMCID: PMC10406403 DOI: 10.5935/2965-2774.20230422-en] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/16/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To assess factors associated with long-term neuropsychiatric outcomes, including biomarkers measured after discharge from the intensive care unit. METHODS A prospective cohort study was performed with 65 intensive care unit survivors. The cognitive evaluation was performed through the Mini-Mental State Examination, the symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale, and posttraumatic stress disorder was evaluated using the Impact of Event Scale-6. Plasma levels of amyloid-beta (1-42) [Aβ (1-42)], Aβ (1-40), interleukin (IL)-10, IL-6, IL-33, IL-4, IL-5, tumor necrosis factor alpha, C-reactive protein, and brain-derived neurotrophic factor were measured at intensive care unit discharge. RESULTS Of the variables associated with intensive care, only delirium was independently related to the occurrence of long-term cognitive impairment. In addition, higher levels of IL-10 and IL-6 were associated with cognitive dysfunction. Only IL-6 was independently associated with depression. Mechanical ventilation, IL-33 levels, and C-reactive protein levels were independently associated with anxiety. No variables were independently associated with posttraumatic stress disorder. CONCLUSION Cognitive dysfunction, as well as symptoms of depression, anxiety, and posttraumatic stress disorder, are present in patients who survive a critical illness, and some of these outcomes are associated with the levels of inflammatory biomarkers measured at discharge from the intensive care unit.
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Affiliation(s)
- Franciani Rodrigues da Rocha
- Laboratory of Translational Biomedicine, Postgraduate Program in
Health Sciences, Universidade do Extremo Sul Catarinense - Criciúma (SC),
Brazil
| | - Renata Casagrande Gonçalves
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
| | - Gabriele da Silveira Prestes
- Laboratory of Translational Biomedicine, Postgraduate Program in
Health Sciences, Universidade do Extremo Sul Catarinense - Criciúma (SC),
Brazil
| | - Danusa Damásio
- Research Centre, Hospital São José - Criciúma
(SC), Brazil
| | - Amanda Indalécio Goulart
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
| | - Andriele Aparecida da Silva Vieira
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
| | - Monique Michels
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
| | - Maria Inês da Rosa
- Laboratory of Translational Biomedicine, Postgraduate Program in
Health Sciences, Universidade do Extremo Sul Catarinense - Criciúma (SC),
Brazil
| | - Cristiane Ritter
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
| | - Felipe Dal-Pizzol
- Laboratory of Experimental Pathophysiology, Postgraduate Program in
Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense -
Criciúma (SC), Brazil
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Kohn R, Weissman GE, Wang W, Ingraham NE, Scott S, Bayes B, Anesi GL, Halpern SD, Kipnis P, Liu VX, Dudley RA, Kerlin MP. Prediction of in-hospital mortality among intensive care unit patients using modified daily Laboratory-based Acute Physiology Scores, version 2 (LAPS2). MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.01.19.23284796. [PMID: 36712116 PMCID: PMC9882631 DOI: 10.1101/2023.01.19.23284796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background Mortality prediction for intensive care unit (ICU) patients frequently relies on single acuity measures based on ICU admission physiology without accounting for subsequent clinical changes. Objectives Evaluate novel models incorporating modified admission and daily, time-updating Laboratory-based Acute Physiology Scores, version 2 (LAPS2) to predict in-hospital mortality among ICU patients. Research design Retrospective cohort study. Subjects All ICU patients in five hospitals from October 2017 through September 2019. Measures We used logistic regression, penalized logistic regression, and random forest models to predict in-hospital mortality within 30 days of ICU admission using admission LAPS2 alone in patient-level and patient-day-level models, or admission and daily LAPS2 at the patient-day level. Multivariable models included patient and admission characteristics. We performed internal-external validation using four hospitals for training and the fifth for validation, repeating analyses for each hospital as the validation set. We assessed performance using scaled Brier scores (SBS), c-statistics, and calibration plots. Results The cohort included 13,993 patients and 120,101 ICU days. The patient-level model including the modified admission LAPS2 without daily LAPS2 had an SBS of 0.175 (95% CI 0.148-0.201) and c-statistic of 0.824 (95% CI 0.808-0.840). Patient-day-level models including daily LAPS2 consistently outperformed models with modified admission LAPS2 alone. Among patients with <50% predicted mortality, daily models were better calibrated than models with modified admission LAPS2 alone. Conclusions Models incorporating daily, time-updating LAPS2 to predict mortality among an ICU population perform as well or better than models incorporating modified admission LAPS2 alone.
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Affiliation(s)
- Rachel Kohn
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, Pennsylvania,Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary E. Weissman
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, Pennsylvania,Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Wang
- Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Stefania Scott
- Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - George L. Anesi
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, Pennsylvania,Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott D. Halpern
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, Pennsylvania,Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania,Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente, Oakland, California
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | | | - Meeta Prasad Kerlin
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, Pennsylvania,Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Pandolfi F, Brun-Buisson C, Guillemot D, Watier L. One-year hospital readmission for recurrent sepsis: associated risk factors and impact on 1-year mortality-a French nationwide study. Crit Care 2022; 26:371. [PMID: 36447252 PMCID: PMC9710072 DOI: 10.1186/s13054-022-04212-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/15/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Sepsis is a complex health condition, leading to long-term morbidity and mortality. Understanding the risk factors for recurrent sepsis, as well as its impact on mid- and long-term mortality among other risk factors, is essential to improve patient survival. METHODS A risk factor analysis, based on French nationwide medico-administrative data, was conducted on a cohort of patients above 15 years old, hospitalized with an incident sepsis in metropolitan France between 1st January 2018 and 31st December 2018 and who survived their index hospitalization. Two main analyses, focusing on outcomes occurring 1-year post-discharge, were conducted: a first one to assess risk factors for recurrent sepsis and a second to assess risk factors for mortality. RESULTS Of the 178017 patients surviving an incident sepsis episode in 2018 and included in this study, 22.3% died during the 1-year period from discharge and 73.8% had at least one hospital readmission in acute care, among which 18.1% were associated with recurrent sepsis. Patients aged between 56 and 75, patients with cancer and renal disease, with a long index hospital stay or with mediastinal or cardiac infection had the highest odds of recurrent sepsis. One-year mortality was higher for patients with hospital readmission for recurrent sepsis (aOR 2.93; 99% CI 2.78-3.09). Among all comorbidities, patients with cancer (aOR 4.35; 99% CI 4.19-4.52) and dementia (aOR 2.02; 99% CI 1.90-2.15) had the highest odds of 1-year mortality. CONCLUSION Hospital readmission for recurrent sepsis is one of the most important risk factors for 1-year mortality of septic patients, along with age and comorbidities. Our study suggests that recurrent sepsis, as well as modifiable or non-modifiable other risk factors identified, should be considered in order to improve patient care pathway and survival.
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Affiliation(s)
- Fanny Pandolfi
- grid.508487.60000 0004 7885 7602Epidemiology and Modeling of Bacterial Evasion to Antibacterials Unit (EMEA), Institut Pasteur, Université Paris Cité, Paris, France ,grid.12832.3a0000 0001 2323 0229Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Versailles Saint Quentin-en-Yvelines/Université Paris Saclay, Paris, France
| | - Christian Brun-Buisson
- grid.508487.60000 0004 7885 7602Epidemiology and Modeling of Bacterial Evasion to Antibacterials Unit (EMEA), Institut Pasteur, Université Paris Cité, Paris, France ,grid.12832.3a0000 0001 2323 0229Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Versailles Saint Quentin-en-Yvelines/Université Paris Saclay, Paris, France
| | - Didier Guillemot
- grid.508487.60000 0004 7885 7602Epidemiology and Modeling of Bacterial Evasion to Antibacterials Unit (EMEA), Institut Pasteur, Université Paris Cité, Paris, France ,grid.12832.3a0000 0001 2323 0229Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Versailles Saint Quentin-en-Yvelines/Université Paris Saclay, Paris, France ,grid.50550.350000 0001 2175 4109AP-HP, Paris Saclay, Public Health, Medical Information, Clinical Research, Le Kremlin-Bicêtre, France
| | - Laurence Watier
- grid.508487.60000 0004 7885 7602Epidemiology and Modeling of Bacterial Evasion to Antibacterials Unit (EMEA), Institut Pasteur, Université Paris Cité, Paris, France ,grid.12832.3a0000 0001 2323 0229Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Versailles Saint Quentin-en-Yvelines/Université Paris Saclay, Paris, France
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10
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Stanculescu D, Bergquist J. Perspective: Drawing on Findings From Critical Illness to Explain Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Front Med (Lausanne) 2022; 9:818728. [PMID: 35345768 PMCID: PMC8957276 DOI: 10.3389/fmed.2022.818728] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/11/2022] [Indexed: 12/15/2022] Open
Abstract
We propose an initial explanation for how myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) could originate and perpetuate by drawing on findings from critical illness research. Specifically, we combine emerging findings regarding (a) hypoperfusion and endotheliopathy, and (b) intestinal injury in these illnesses with our previously published hypothesis about the role of (c) pituitary suppression, and (d) low thyroid hormone function associated with redox imbalance in ME/CFS. Moreover, we describe interlinkages between these pathophysiological mechanisms as well as “vicious cycles” involving cytokines and inflammation that may contribute to explain the chronic nature of these illnesses. This paper summarizes and expands on our previous publications about the relevance of findings from critical illness for ME/CFS. New knowledge on diagnostics, prognostics and treatment strategies could be gained through active collaboration between critical illness and ME/CFS researchers, which could lead to improved outcomes for both conditions.
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Affiliation(s)
| | - Jonas Bergquist
- Division of Analytical Chemistry and Neurochemistry, Department of Chemistry - Biomedical Center, Uppsala University, Uppsala, Sweden.,The Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Collaborative Research Centre at Uppsala University, Uppsala, Sweden
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11
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Improving nutritional therapy of persistent critically ill patients by organisational measures: A before and after study. Clin Nutr ESPEN 2021; 46:459-465. [PMID: 34857234 DOI: 10.1016/j.clnesp.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 07/07/2021] [Accepted: 09/15/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND & AIMS Critically ill patients requiring prolonged intensive care (ICU) treatment are at high risk of malnutrition, which latter contributes to worsening outcome. Having observed that despite the presence of a nutrition protocol and dieticians, the patients with persistent critical illness (PCI) had been underfed during their ICU stay and particularly during the first 10 days, the aim was to analyse the impact of the organisational changes that were proposed to prevent the observed malnutrition. METHODS Before (Period A) and after (Period B) study enrolling critically ill patients consecutively admitted, requiring >10 days of ICU treatment. The intervention consisted in increasing the early morning interactions between dieticians, nurses, and physicians, while modifying the computer visualisation of the dietician proposals. The primary endpoint was a reduction in the cumulative energy balance in period B. The ICU stay was divided in early ICU stay (first 10 days) and late ICU stay (day 11 to day 30). Other variables: protein, glucose, and prealbumin. RESULTS Altogether, 205 patients (150 and 55 in period A and B respectively) were enrolled in the PCI program. Patient characteristics were similar over both periods except for lower SAPSII score in period B. There was no difference in nutritional pattern in the first 10 days between periods. The cumulate energy balance was less negative from day 11-30 in period B than in A (-884 vs -1566 kcal; p = 0.033). There was a one-day reduction in the median duration of fasting in period B (p < 0.0001). Overall compliance with nutrition protocol improved in period B with an earlier first indirect calorimetry (p = 0.003) and prealbumin measurement (p < 0.001), the latter increasing significantly more during ICU stay. CONCLUSION Organizational changes that allowed an early identification of patients at nutritional risk, an increased targeted dieticians intervention and a better inter-disciplinary work was associated with a reduction in undue fasting, and significantly improved energy balances.
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12
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Rose L, Allum LJ, Istanboulian L, Dale C. Actionable processes of care important to patients and family who experienced a prolonged intensive care unit stay: Qualitative interview study. J Adv Nurs 2021; 78:1089-1099. [PMID: 34704627 DOI: 10.1111/jan.15083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/12/2021] [Accepted: 10/16/2021] [Indexed: 11/30/2022]
Abstract
AIM To use positive deviance to identify actionable processes of care that may improve outcomes and experience from the perspectives of prolonged intensive care unit (ICU) stay survivors and family members. DESIGN Prospective qualitative interview study in two geographically distant settings: Canada (2018/19) and the United Kingdom (2019/20). METHODS Patient and family participant inclusion criteria comprised: aged over 18 years, ICU stay in last 2 years of over 7 days, able to recall ICU stay and provided informed consent. We conducted semi-structured in-person or telephone interviews. Data were analysed using a positive deviance approach. RESULTS We recruited 29 participants (15 Canadian; 14 UK). Of these, 11 were survivors of prolonged ICU stay and 18 family members. We identified 22 actionable processes (16 common to Canadian and UK participants, 4 Canadian only and 2 UK only). We grouped processes under three themes: physical and functional recovery (nine processes), patient psychological well-being (seven processes) and family relations (six processes). Most commonly identified physical/functional processes were regular physiotherapy, and fundamental hygiene and elimination care. For patient psychological well-being: normalizing the environment and routines, and alleviating boredom and loneliness. For family relations: proactive communication, flexible family visiting and presence with facilities for family. Our positive deviance analysis approach revealed that incorporation of these actionable processes into clinical practice was the exception as opposed to the norm perceived driven by individual acts of kindness and empathy as opposed to standardized processes. CONCLUSION Actionable processes of care important to prolonged ICU stay survivors and family members differ from those frequently used in ICU quality improvement (QI) tools. IMPACT Our study emphasizes the need to develop QI tools that standardize delivery of actionable processes important to patients and families experiencing a prolonged ICU stay. As the largest healthcare professional group, nurses can play an essential role in leading this.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,Critical Care and Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Laura J Allum
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Laura Istanboulian
- Michael Garron Hospital, Toronto, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Craig Dale
- Lawrence S. Bloomberg Faculty of Nursing and Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Canada
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13
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Darden DB, Dong X, Brusko MA, Kelly L, Fenner B, Rincon JC, Dirain ML, Ungaro R, Nacionales DC, Gauthier M, Kladde M, Brusko TM, Bihorac A, Moore FA, Loftus T, Bacher R, Moldawer LL, Mohr AM, Efron PA. A Novel Single Cell RNA-seq Analysis of Non-Myeloid Circulating Cells in Late Sepsis. Front Immunol 2021; 12:696536. [PMID: 34484194 PMCID: PMC8415415 DOI: 10.3389/fimmu.2021.696536] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/30/2021] [Indexed: 12/11/2022] Open
Abstract
Background With the successful implementation of the Surviving Sepsis Campaign guidelines, post-sepsis in-hospital mortality to sepsis continues to decrease. Those who acutely survive surgical sepsis will either rapidly recover or develop a chronic critical illness (CCI). CCI is associated with adverse long-term outcomes and 1-year mortality. Although the pathobiology of CCI remains undefined, emerging evidence suggests a post-sepsis state of pathologic myeloid activation, inducing suboptimal lymphopoiesis and erythropoiesis, as well as downstream leukocyte dysfunction. Our goal was to use single-cell RNA sequencing (scRNA-seq) to perform a detailed transcriptomic analysis of lymphoid-derived leukocytes to better understand the pathology of late sepsis. Methods A mixture of whole blood myeloid-enriched and Ficoll-enriched peripheral blood mononuclear cells from four late septic patients (post-sepsis day 14-21) and five healthy subjects underwent Cellular Indexing of Transcriptomes and Epitopes by Sequencing (CITE-seq). Results We identified unique transcriptomic patterns for multiple circulating immune cell subtypes, including B- and CD4+, CD8+, activated CD4+ and activated CD8+ T-lymphocytes, as well as natural killer (NK), NKT, and plasmacytoid dendritic cells in late sepsis patients. Analysis demonstrated that the circulating lymphoid cells maintained a transcriptome reflecting immunosuppression and low-grade inflammation. We also identified transcriptomic differences between patients with bacterial versus fungal sepsis, such as greater expression of cytotoxic genes among CD8+ T-lymphocytes in late bacterial sepsis. Conclusion Circulating non-myeloid cells display a unique transcriptomic pattern late after sepsis. Non-myeloid leukocytes in particular reveal a host endotype of inflammation, immunosuppression, and dysfunction, suggesting a role for precision medicine-guided immunomodulatory therapy.
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Affiliation(s)
- Dijoia B Darden
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Xiaoru Dong
- Department of Biomedical Engineering, University of Florida College of Medicine, Gainesville, FL, United States
| | - Maigan A Brusko
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, United States
| | - Lauren Kelly
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Brittany Fenner
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Jaimar C Rincon
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Marvin L Dirain
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Ricardo Ungaro
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Dina C Nacionales
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Marie Gauthier
- Department of Biochemistry and Molecular Biology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Michael Kladde
- Department of Biochemistry and Molecular Biology, University of Florida College of Medicine, Gainesville, FL, United States
| | - Todd M Brusko
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, United States
| | - Azra Bihorac
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, United States
| | - Frederick A Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Tyler Loftus
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Rhonda Bacher
- Department of Biostatistics, University of Florida, Gainesville, FL, United States
| | - Lyle L Moldawer
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Alicia M Mohr
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
| | - Philip A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, United States
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14
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Suter P, Wesch C. Erste Evaluation eines Programms zur Frührehabilitation von Langzeitintensivpatient_innen. Pflege 2021; 34:291-299. [PMID: 34463542 DOI: 10.1024/1012-5302/a000830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
First evaluation of an early rehabilitation programm for chronically critically ill patients Abstract. Introduction: Chronically critically ill patients are an increasing challenge for teams in intensive care units due to the burden of symptoms and the consumption of resources. Structured multimodal concepts are recommended for nursing care and treatment. A local, interprofessional program for early rehabilitation aims to provide optimal care for patients through a systematic, proactive and holistic treatment process with a rehabilitative focus. The program consists of specific assessments and systematic coordination of interprofessional early rehabilitation. Problem and objective: Interprofessional collaboration requires mutual acceptance and good communication from those involved. The functioning of selected processes as well as the satisfaction of the professionals are topics of a first formative evaluation. Methods: The team evaluated descriptive quality data as well as self-generated structured questionnaires. Results: Specific adjustments were made to the treatment plan for 52 of 112 patients in the program. The assessments are easy to carry out and support systematic early rehabilitation. From the perspective of the professionals involved, both the interprofessional collaboration and their understanding for the patients improved. Discussion and transfer: The program optimizes treatment and promotes good interprofessional collaboration. The formative evaluation provides valuable information for future process changes such as the inclusion of patients as well as further disciplines and program development beyond the boundaries of the intensive care unit.
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Affiliation(s)
- Peter Suter
- Praxisentwicklung und Forschung Therapien, Universitätsspital Basel
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15
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Núñez SA, Roveda G, Zárate MS, Emmerich M, Verón MT. Ventilator-associated pneumonia in patients on prolonged mechanical ventilation: description, risk factors for mortality, and performance of the SOFA score. ACTA ACUST UNITED AC 2021; 47:e20200569. [PMID: 34190861 PMCID: PMC8332725 DOI: 10.36416/1806-3756/e20200569] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/22/2021] [Indexed: 12/30/2022]
Abstract
Objective: Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation (MV). However, data on VAP in patients on prolonged MV (PMV) are scarce. We aimed to describe the characteristics of VAP patients on PMV and to identify factors associated with mortality. Methods: This was a retrospective cohort study including VAP patients on PMV. We recorded baseline characteristics, as well as 30-day and 90-day mortality rates. Variables associated with mortality were determined by Kaplan-Meier survival analysis and Cox regression model. Results: We identified 80 episodes of VAP in 62 subjects on PMV. The medians for age, Charlson Comorbidity Index, SOFA score, and days on MV were, respectively, 69.5 years, 5, 4, and 56 days. Episodes of VAP occurred between days 21 and 50 of MV in 28 patients (45.2%) and, by day 90 of MV, in 48 patients (77.4%). The 30-day and 90-day mortality rates were 30.0% and 63.7%, respectively. There were associations of 30-day mortality with the SOFA score (hazard ratio [HR] = 1.30; 95% CI: 1.12-1.52; p < 0.001) and use of vasoactive agents (HR = 4.0; 95% CI: 1.2-12.9; p = 0.02), whereas 90-day mortality was associated with age (HR = 1.03; 95% CI: 1.00-1.05; p = 0.003), SOFA score (HR = 1.20; 95% CI: 1.07-1.34; p = 0.001), use of vasoactive agents (HR = 4.07; 95% CI: 1.93-8.55; p < 0.001), and COPD (HR = 3.35; 95% CI: 1.71-6.60; p < 0.001). Conclusions: Mortality rates in VAP patients on PMV are considerably high. The onset of VAP can occur various days after MV initiation. The SOFA score is useful for predicting fatal outcomes. The factors associated with mortality could help guide therapeutic decisions and determine prognosis.
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Affiliation(s)
| | | | | | - Mónica Emmerich
- . Unidad de Paciente Critico Crónico, Sanatorio Güemes, Buenos Aires, Argentina
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16
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Demirkiran H, Kilic M, Tomak Y, Dalkiran T, Yurttutan S, Basaranoglu M, Tuncer O, Derme T, Tekeli AE, Bahar I, Keskin S, Oksuz H. Evaluation of the incidence, characteristics, and outcomes of pediatric chronic critical illness. PLoS One 2021; 16:e0248883. [PMID: 34048449 PMCID: PMC8162636 DOI: 10.1371/journal.pone.0248883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/06/2021] [Indexed: 11/18/2022] Open
Abstract
Our aim was to determine characteristics of children with chronic critical illness (CCI) admitted to the pediatric intensive care unit (PICU) of a tertiary care children's hospital in Turkey. The current study was a multicenter retrospective cohort study that was done from 2014 to 2017. It involved three university hospitals PICUs in which multiple criteria were set to identify pediatric CCIs. Pediatric patients staying in the ICU for at least 14 days and having at least one additional criterion, including prolonged mechanical ventilation, tracheostomy, sepsis, severe wound (burn) or trauma, encephalopathy, traumatic brain injury, status epilepticus, being postoperative, and neuromuscular disease, was accepted as CCI. In order to identify the newborn as a chronic critical patient, a stay in the intensive care unit for at least 30 days in addition to prematurity was required. Eight hundred eighty seven (11.14%) of the patients who were admitted to the PICU met the definition of CCI and 775 of them (87.3%) were discharged to their home. Of CCI patients, 289 (32.6%) were premature and 678 (76.4%) had prolonged mechanical ventilation. The total cost values for 2017 were statistically higher than the other years. As the length of ICU stay increased, the costs also increased. Interestingly, high incidence rates were observed for PCCI in our hospitals and these patients occupied 38.01% of the intensive care bed capacity. In conclusion, we observed that prematurity and prolonged mechanical ventilation increase the length of ICU stay, which also increased the costs. More work is needed to better understand PCCI.
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Affiliation(s)
- Hilmi Demirkiran
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
- * E-mail:
| | - Mehmet Kilic
- Department of Pediatrics, Hisar Intercontinental Hospital, Istanbul, Turkey
| | - Yakup Tomak
- Anesthesiology and Intensive Care Unit, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Tahir Dalkiran
- Pediatric Intensive Care Unit, Necip Fazil City Hospital, Kahramanmaras, Turkey
| | - Sadik Yurttutan
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
| | - Murat Basaranoglu
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Oguz Tuncer
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Turan Derme
- Department of Pediatrics, Division of Neonatology, Ministry of Health Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Arzu Esen Tekeli
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Ilhan Bahar
- Internal Medicine Critical Care Unit, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Siddik Keskin
- Department of Biostatistics, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey
| | - Hafize Oksuz
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
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17
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Stanculescu D, Larsson L, Bergquist J. Theory: Treatments for Prolonged ICU Patients May Provide New Therapeutic Avenues for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Front Med (Lausanne) 2021; 8:672370. [PMID: 34026797 PMCID: PMC8137963 DOI: 10.3389/fmed.2021.672370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/01/2021] [Indexed: 12/20/2022] Open
Abstract
We here provide an overview of treatment trials for prolonged intensive care unit (ICU) patients and theorize about their relevance for potential treatment of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Specifically, these treatment trials generally target: (a) the correction of suppressed endocrine axes, notably through a "reactivation" of the pituitary gland's pulsatile secretion of tropic hormones, or (b) the interruption of the "vicious circle" between inflammation, oxidative and nitrosative stress (O&NS), and low thyroid hormone function. There are significant parallels in the treatment trials for prolonged critical illness and ME/CFS; this is consistent with the hypothesis of an overlap in the mechanisms that prevent recovery in both conditions. Early successes in the simultaneous reactivation of pulsatile pituitary secretions in ICU patients-and the resulting positive metabolic effects-could indicate an avenue for treating ME/CFS. The therapeutic effects of thyroid hormones-including in mitigating O&NS and inflammation and in stimulating the adreno-cortical axis-also merit further studies. Collaborative research projects should further investigate the lessons from treatment trials for prolonged critical illness for solving ME/CFS.
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Affiliation(s)
| | - Lars Larsson
- Basic and Clinical Muscle Biology, Department of Physiology and Pharmacology, Karolinska Institute, Solna, Sweden
| | - Jonas Bergquist
- Analytical Chemistry and Neurochemistry, Department of Chemistry–Biomedical Center, Uppsala University, Uppsala, Sweden
- The Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Collaborative Research Centre at Uppsala University, Uppsala, Sweden
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18
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Ramakrishnan N. Chronic Critical Illness: Are We Just Adding Years to Life? Indian J Crit Care Med 2021; 25:482-483. [PMID: 34177161 PMCID: PMC8196377 DOI: 10.5005/jp-journals-10071-23831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
How to cite this article: Ramakrishnan N. Chronic Critical Illness: Are We Just Adding Years to Life? Indian J Crit Care Med 2020;25(5):482-483.
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19
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Henrique LR, Crispim D, Vieceli T, Schaeffer AF, Bellaver P, Leitão CB, Rech TH. Copeptin and stress-induced hyperglycemia in critically ill patients: A prospective study. PLoS One 2021; 16:e0250035. [PMID: 33882083 PMCID: PMC8059855 DOI: 10.1371/journal.pone.0250035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/29/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives Copeptin, an equimolar indicator of serum antidiuretic hormone levels, has been associated with higher mortality in critically ill patients and with the development of diabetes in the general population. The aim of the present study was to investigate the association of copeptin levels with glycemic parameters in critically ill patients and to compare the time-course of copeptin in survivors and non-survivors. Design Prospective cohort study. Patients From June to October 2019, critically ill patients were prospectively enrolled and followed for 90 days. Measurements Plasma copeptin levels were determined at intensive care unit (ICU) admission (copeptin T1), 24 h (copeptin T2), and 48 h (copeptin T3) after study entry. Blood glucose and glycated hemoglobin levels were measured. ICU, in-hospital, and 90-day mortality, and length of stay in the ICU and hospital were evaluated. Results 104 patients were included. No significant correlation was detected between copeptin levels and blood glucose (r = -0.17, p = 0.09), HbA1c (r = 0.01, p = 0.9), glycemic gap (r = -0.16, p = 0.11), and stress hyperglycemia ratio (r = -0.14, p = 0.16). Copeptin T3 levels were significantly higher in survivors than in non-survivors at hospital discharge (561 [370–856] vs 300 [231–693] pg/mL, p = 0.015) and at 90 days (571 [380–884] vs 300 [232–698] pg/mL, p = 0.03). Conclusions No significant correlations were found between copeptin levels and glycemic parameters, suggesting that copeptin is not a relevant factor in the induction of hyperglycemia during critical illness. Copeptin levels at ICU day 3 were higher in survivors than in non-survivors.
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Affiliation(s)
- Lilian Rodrigues Henrique
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Daisy Crispim
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Tarsila Vieceli
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ariell Freires Schaeffer
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Priscila Bellaver
- Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Cristiane Bauermann Leitão
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Tatiana Helena Rech
- Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- * E-mail:
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20
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Darden DB, Kelly LS, Fenner BP, Moldawer LL, Mohr AM, Efron PA. Dysregulated Immunity and Immunotherapy after Sepsis. J Clin Med 2021; 10:jcm10081742. [PMID: 33920518 PMCID: PMC8073536 DOI: 10.3390/jcm10081742] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/08/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
Implementation of protocolized surveillance, diagnosis, and management of septic patients, and of surgical sepsis patients in particular, is shown to result in significantly increased numbers of patients surviving their initial hospitalization. Currently, most surgical sepsis patients will rapidly recover from sepsis; however, many patients will not rapidly recover, but instead will go on to develop chronic critical illness (CCI) and experience dismal long-term outcomes. The elderly and comorbid patient is highly susceptible to death or CCI after sepsis. Here, we review aspects of the Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) endotype to explain the underlying pathobiology of a dysregulated immune system in sepsis survivors who develop CCI; then, we explore targets for immunomodulatory therapy.
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21
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Indwelling Device-Associated Biofilms in Critically Ill Cancer Patients-Study Protocol. Pathogens 2021; 10:pathogens10030306. [PMID: 33800769 PMCID: PMC8001301 DOI: 10.3390/pathogens10030306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/28/2021] [Accepted: 03/03/2021] [Indexed: 11/26/2022] Open
Abstract
Health care-associated infections are a leading cause of inpatient complications. Rapid pathogen detection/identification is a major challenge in sepsis management that highly influences the successful outcome. The current standard of microorganism identification relies on bacterial growth in culture, which has several limitations. Gene sequencing research has developed culture-independent techniques for microorganism identification, with the aim to improve etiological diagnosis and, therefore, to change sepsis outcome. A prospective, observational, non-interventional, single-center study was designed that assesses biofilm-associated pathogens in a specific subpopulation of septic critically ill cancer patients. Indwelling device samples will be collected in septic patients at the moment of the removal of the arterial catheter, central venous catheter, endotracheal tube and urinary catheter. Concomitantly, clinical data regarding 4 sites (nasal, pharyngeal, rectal and skin) of pathogen colonization at the time of hospital/intensive care admission will be collected. The present study aims to offer new insights into biofilm-associated infections and to evaluate the infection caused by catheter-specific and patient-specific biofilm-associated pathogens in association with the extent of colonization. The analysis relies on the two following detection/identification techniques: standard microbiological method and next generation sequencing (NGS). Retrospectively, the study will estimate the clinical value of the NGS-based detection and its virtual potential in changing patient management and outcome, notably in the subjects with missing sepsis source or lack of response to anti-infective treatment.
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Fenner BP, Darden DB, Kelly LS, Rincon J, Brakenridge SC, Larson SD, Moore FA, Efron PA, Moldawer LL. Immunological Endotyping of Chronic Critical Illness After Severe Sepsis. Front Med (Lausanne) 2021; 7:616694. [PMID: 33659259 PMCID: PMC7917137 DOI: 10.3389/fmed.2020.616694] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/14/2020] [Indexed: 12/15/2022] Open
Abstract
Improved management of severe sepsis has been one of the major health care accomplishments of the last two decades. Due to enhanced recognition and improved management of severe sepsis, in-hospital mortality has been reduced by up to 40%. With that good news, a new syndrome has unfortunately replaced in-hospital multi-organ failure and death. This syndrome of chronic critical illness (CCI) includes sepsis patients who survive the early "cytokine or genomic storm," but fail to fully recover, and progress into a persistent state of manageable organ injury requiring prolonged intensive care. These patients are commonly discharged to long-term care facilities where sepsis recidivism is high. As many as 33% of sepsis survivors develop CCI. CCI is the result, at least in part, of a maladaptive host response to chronic pattern-recognition receptor (PRR)-mediated processes. This maladaptive response results in dysregulated myelopoiesis, chronic inflammation, T-cell atrophy, T-cell exhaustion, and the expansion of suppressor cell functions. We have defined this panoply of host responses as a persistent inflammatory, immune suppressive and protein catabolic syndrome (PICS). Why is this important? We propose that PICS in survivors of critical illness is its own common, unique immunological endotype driven by the constant release of organ injury-associated, endogenous alarmins, and microbial products from secondary infections. While this syndrome can develop as a result of a diverse set of pathologies, it represents a shared outcome with a unique underlying pathobiological mechanism. Despite being a common outcome, there are no therapeutic interventions other than supportive therapies for this common disorder. Only through an improved understanding of the immunological endotype of PICS can rational therapeutic interventions be designed.
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Affiliation(s)
- Brittany P Fenner
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - D B Darden
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Lauren S Kelly
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Jaimar Rincon
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Scott C Brakenridge
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Shawn D Larson
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Frederick A Moore
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Philip A Efron
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
| | - Lyle L Moldawer
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, FL, United States
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Stanculescu D, Larsson L, Bergquist J. Hypothesis: Mechanisms That Prevent Recovery in Prolonged ICU Patients Also Underlie Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Front Med (Lausanne) 2021; 8:628029. [PMID: 33585528 PMCID: PMC7876311 DOI: 10.3389/fmed.2021.628029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/08/2021] [Indexed: 12/13/2022] Open
Abstract
Here the hypothesis is advanced that maladaptive mechanisms that prevent recovery in some intensive care unit (ICU) patients may also underlie Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Specifically, these mechanisms are: (a) suppression of the pituitary gland's pulsatile secretion of tropic hormones, and (b) a "vicious circle" between inflammation, oxidative and nitrosative stress (O&NS), and low thyroid hormone function. This hypothesis should be investigated through collaborative research projects.
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Affiliation(s)
| | - Lars Larsson
- Basic and Clinical Muscle Biology, Department of Physiology and Pharmacology, Karolinska Institute, Solna, Sweden
| | - Jonas Bergquist
- Analytical Chemistry and Neurochemistry, Department of Chemistry – Biomedical Center, Uppsala University, Uppsala, Sweden
- The Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Collaborative Research Centre at Uppsala University, Uppsala, Sweden
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Yildirim S, Durmaz Y, Şan Y, Taşkıran İ, Cinleti BA, Kirakli C. Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country. Indian J Crit Care Med 2021; 25:519-523. [PMID: 34177170 PMCID: PMC8196383 DOI: 10.5005/jp-journals-10071-23804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background An increasing number of patients become chronic critically ill (CCI) and dependent on long-term therapies in the intensive care unit (ICU). Mortality and healthcare costs increase in these patients. In order to deal with this problem, the magnitude and risk factors for CCI must first be determined. Therefore, we aimed at evaluating the incidence cost and risk factors for CCI in our ICU. Materials and methods This retrospective cohort study was compiled by recruiting patients admitted to our ICU between January 1, 2017, and December 31, 2018. Patients with an ICU stay of more than 21 days were defined as CCI. Patients who did not survive in the first 21 days were excluded from the study because it could be not known whether these patients would progress to CCI. During the study period, 1,166 patients were followed up, and 475 (40%) of them were excluded and 691 patients were included in the final analyses. Results During the study period, 691 patients were included in the study and 152 of them (22%) were CCI. Age, acute physiology and chronic health evaluation (APACHE)-2 score, length of stay, and daily costs were higher in patients with CCI. The cost for a patient with CCI is sixfold that of a patient without CCI. ICU mortality was 47% in patients without CCI and 54% in the CCI patients (p < 0.001). Conclusion CCI affects an increasing number of patients and leads to increased mortality rates and cost. Prolonged duration in ICU may cause complications such as secondary infections, sepsis episodes, and acute renal injury. The treatment of these complications may lead to increased mortality and cost. How to cite this article Yildirim S, Durmaz Y, Şan Y, Taşkiran İ, Cinleti BA, Kirakli C. Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country. Indian J Crit Care Med 2021;25(5):519–523.
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Affiliation(s)
- Süleyman Yildirim
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - Yusuf Durmaz
- Department of Intensive Care Unit, Hakkari Public Hospital, Hakkari, Turkey
| | - Yosun Şan
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - İmren Taşkıran
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - Burcu A Cinleti
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - Cenk Kirakli
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
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Bento Talizin T, Dantas de Maio Carrilho CM, Magalhães Carvalho Grion C, Tibery Queiroz Cardoso L, Toshiyuki Tanita M, Boll KM, Moro Kauss IA, Festti J, Ribeiro Lopes C, Alves da Silva LM, Patruceli de Azevedo I, Paes K, Medeiros EA. Polymyxin for treatment of ventilator-associated pneumonia in a setting of high carbapenem resistance. PLoS One 2020; 15:e0237880. [PMID: 32813749 PMCID: PMC7437913 DOI: 10.1371/journal.pone.0237880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/04/2020] [Indexed: 12/16/2022] Open
Abstract
Objectives To analyse the use of polymyxins for the treatment of ventilator-associated pneumonia (VAP) at a teaching hospital where carbapenem-resistant gram-negative bacteria are endemic. Patients and methods This was a historical cohort study of patients receiving polymyxins to treat VAP in ICUs at a public university hospital in southern Brazil between January 1, 2017 and January 31, 2018. Results During the study period, 179 cases of VAP were treated with polymyxins. Of the 179 patients, 158 (88.3%) were classified as having chronic critical illness. Death occurred in 145 cases (81.0%). Multivariate analysis showed that the factors independently associated with mortality were the presence of comorbidities (P<0.001) and the SOFA score of the day of polymyxin prescription (P<0.001). Being a burn patient was a protective factor for mortality (P<0.001). Analysis of the 14-day survival probability showed that mortality was higher among the patients who had sepsis or septic shock at the time of polymyxin prescription (P = 0.028 and P<0.001, respectively). Acinetobacter baumannii was identified as the etiological agent of VAP in 121 cases (67.6%). In our cohort, polymyxin consumption and the incidence density of VAP were quite high. Conclusions In our study, comprised primarily of chronically critically ill patients, there was a high prevalence of VAP caused by multidrug-resistant bacteria, consistent with healthcare-associated infections in low- and middle-income countries. Presence of comorbidities and the SOFA score at the time of polymyxin prescription were predictors of mortality in this cohort. Despite aggressive antimicrobial treatment, mortality was high, stressing the need for antibiotic stewardship.
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Affiliation(s)
- Thalita Bento Talizin
- Comissão de Epidemiologia Hospitalar, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
- Medical School, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- * E-mail:
| | | | | | | | - Marcos Toshiyuki Tanita
- Hospital Universitário da Universidade Estadual de Londrina, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Karine Maria Boll
- Hospital Universitário da Universidade Estadual de Londrina, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Ivanil Aparecida Moro Kauss
- Hospital Universitário da Universidade Estadual de Londrina, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Josiane Festti
- Hospital Universitário da Universidade Estadual de Londrina, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | | | | | | | - Késia Paes
- Medical School, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Eduardo Alexandrino Medeiros
- Comissão de Epidemiologia Hospitalar, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
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Cox MC, Brakenridge SC, Stortz JA, Hawkins RB, Darden DB, Ghita GL, Mohr AM, Moldawer LL, Efron PA, Moore FA. Abdominal sepsis patients have a high incidence of chronic critical illness with dismal long-term outcomes. Am J Surg 2020; 220:1467-1474. [PMID: 32807383 DOI: 10.1016/j.amjsurg.2020.07.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/20/2020] [Accepted: 07/16/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND As hospital sepsis mortality has decreased, more surgical ICU survivors are progressing into chronic critical illness (CCI). This study documents the incidence of CCI and long-term outcomes of patients with abdominal sepsis. We hypothesized that patients developing CCI would have biomarker evidence of immune and metabolic derangement, with a high incidence of poor 1-year outcomes. METHODS Review of abdominal sepsis patients entered in a prospective longitudinal study of surgical ICU sepsis. RESULTS Of the 144 study patients, only 6% died early, 37% developed CCI (defined as ICU days ≥14 with organ dysfunction) and 57% were classified rapid recovery (RAP). Compared to RAP, CCI patients a) were older (66 vs 58), males who were sicker at baseline (Charlson Comorbidity Index 4 vs 2), b) had persistently elevated biomarkers of dysregulated immunity/metabolism (IL-6, IL-8, sPDL-1, GLP1), c) experienced more secondary infections (4.9 vs 2.3) and organ failure (Denver MOF frequency 40 vs 1%), d) were much more likely to have poor dispositions (85 vs 22%) with severe persistent disabilities by Zubrod Score and e) had a notably higher 1-year mortality of 42% (all p < 0.05). CONCLUSION Over 1/3rd surgical ICU patients treated for abdominal sepsis progress into CCI and experience dismal long-term outcomes.
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Affiliation(s)
- Michael C Cox
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Scott C Brakenridge
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Julie A Stortz
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Russell B Hawkins
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Dijoa B Darden
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Gabriela L Ghita
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Alicia M Mohr
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Lyle L Moldawer
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Philip A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Frederick A Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
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Brinati LM, de Fátima Januário C, Balbino PC, Gonçalves Rezende Macieira T, Cardoso SA, Moreira TR, de Oliveira Salgado P. Incidence and Prediction of Unstable Blood Glucose Level among Critically Ill Patients: A Cohort Study. Int J Nurs Knowl 2020; 32:96-102. [PMID: 32706490 DOI: 10.1111/2047-3095.12299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 01/18/2023]
Abstract
PURPOSE To evaluate the incidence and the prediction of unstable blood glucose level among critically ill patients hospitalized in an intensive care unit. METHODS A cohort study was conducted with 62 adult patients hospitalized at an intensive care unit of a hospital located in Minas Gerais, Brazil, between March and July of 2017. Patient's demographic information, along with scores for Simplified Acute Physiology Score III, primary medical diagnosis, discharge status, diagnosis of diabetes and/or sepsis, length of stay, glycemic variability, type of nutrition, types of medications and treatments, and oxygen therapy were collected daily. A daily venous blood sample was collected to measure blood glucose levels during the patient's hospitalization period. Bivariate analysis was used to explore the association among the potential diagnostic indicators and the outcome of unstable blood glucose levels. Multivariate Cox regression was used to identify the potential predictors for the outcome. FINDINGS Of the total of 62 participants, 45.1% (n=28) had unstable blood glucose level. Among the 28 patients with unstable blood glucose levels, half of them (n=14, 50%) had hypoglycemia and the other half had hyperglycemia (n=14, 50%). Decreased number of days hospitalized and the use of intensive glucose control with regular insulin were associated with decreased odds of developing hyperglycemia. The presence of mechanical ventilation was associated with a higher risk for the development of hypoglycemia. CONCLUSIONS This study provides knowledge and evidence of diagnostic indicators for unstable blood glucose levels that are not currently included in the NANDA-International terminology for the nursing diagnosis Risk for unstable blood glucose level (00179). IMPLICATIONS FOR NURSING PRACTICE This study identified important diagnostic indicators that nurses can observe during the assessment to identify patients that are at risk for developing unstable blood glucose level and provide the appropriate care.
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Affiliation(s)
- Lídia Miranda Brinati
- Lídia Miranda Brinati, MSN, RN, is in, Centro de Terapia Intensiva Adulto Casa de Caridade de Viçosa Hospital São Sebastião, Viçosa, MG, Brazil
| | | | - Paula Coelho Balbino
- Paula Coelho Balbino, RN, is in, Núcleo de Segurança do Paciente Hospital São João Batista, Viçosa, MG, Brazil
| | - Tamara Gonçalves Rezende Macieira
- Tamara Gonçalves Rezende Macieira, PhD, RN, is an Assistant Professor in College of Nursing, University of Florida, Gainesville, Florida
| | - Silvia Almeida Cardoso
- Silvia Almeida Cardoso, PhD, is an Assistant Professor in Department of Medicine and Nursing, Federal University of Viçosa (UFV), Viçosa, MG, Brazil
| | - Tiago Ricardo Moreira
- Tiago Ricardo Moreira, PhD, is an Assistant Professor in Department of Medicine and Nursing, Federal University of Viçosa (UFV), Viçosa, MG, Brazil
| | - Patrícia de Oliveira Salgado
- Patrícia de Oliveira Salgado, PhD, RN, is an Assistant Professor in Department of Medicine and Nursing, Federal University of Viçosa (UFV), Viçosa, MG, Brazil
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Vargas MADO, Peter E, Luz KRD, Barlem ELD, Ventura CAA, Nascimento ERPD. Management of bed availability in intensive care in the context of hospitalization by court order. Rev Lat Am Enfermagem 2020; 28:e3271. [PMID: 32401898 PMCID: PMC7217627 DOI: 10.1590/1518-8345.3420.3271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 02/13/2020] [Indexed: 12/03/2022] Open
Abstract
Objective: to identify, from the nurse perspective, situations that interfere with the
availability of beds in the intensive care unit in the context of
hospitalization by court order. Method: qualitative exploratory, analytical research carried out with 42 nurses
working in adult intensive care. The selection took place by
non-probabilistic snowball sampling. Data collected by interview and
analyzed using the Discursive Textual Analysis technique. Results: three categories were analyzed, entitled deficiency of physical structure and
human resources; Lack of clear policies and criteria for patient admission
and inadequate discharge from the intensive care unit. In situations of
hospitalization by court order, there is a change in the criteria for the
allocation of intensive care beds, due to the credibility of professionals,
threats of medico-legal processes by family members and judicial imposition
on institutions and health professionals. Conclusion: nurses defend the needs of the patients, too, with actions that can
positively impact the availability of intensive care beds and adequate care
infrastructure.
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Affiliation(s)
| | - Elizabeth Peter
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Kely Regina da Luz
- Departamento de Enfermagem, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | | | - Carla Aparecida Arena Ventura
- Collaborating Centre OPS/OMS for Nursing Development Research, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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29
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Berger MM. Nutrition determines outcome after severe burns. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S216. [PMID: 31656795 DOI: 10.21037/atm.2019.08.57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mette M Berger
- Service of Adult Intensive Care and Burns, Lausanne University hospital - CHUV, Lausanne, Switzerland
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30
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Viana MV, Pantet O, Bagnoud G, Martinez A, Favre E, Charrière M, Favre D, Eckert P, Berger MM. Metabolic and Nutritional Characteristics of Long-Stay Critically Ill Patients. J Clin Med 2019; 8:jcm8070985. [PMID: 31284633 PMCID: PMC6679172 DOI: 10.3390/jcm8070985] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/02/2019] [Accepted: 07/04/2019] [Indexed: 12/26/2022] Open
Abstract
Background: insufficient feeding is frequent in the intensive care unit (ICU), which results in poor outcomes. Little is known about the nutrition pattern of patients requiring prolonged ICU stays. The aims of our study are to describe the demographic, metabolic, and nutritional specificities of chronically critically ill (CCI) patients defined by an ICU stay >2 weeks, and to identify an early risk factor. Methods: analysis of consecutive patients prospectively admitted to the CCI program, with the following variables: demographic characteristics, Nutrition Risk Screening (NRS-2002) score, total daily energy from nutritional and non-nutritional sources, protein and glucose intakes, all arterial blood glucose values, length of ICU and hospital stay, and outcome (ICU and 90-day survival). Two phases were considered for the analysis: the first 10 days, and the next 20 days of the ICU stay. Statistics: parametric and non-parametric tests. Results: 150 patients, aged 60 ± 15 years were prospectively included. Median (Q1, Q3) length of ICU stay was 31 (26, 46) days. The mortality was 18% at ICU discharge and 35.3% at 90 days. Non-survivors were older (p = 0.024), tended to have a higher SAPSII score (p = 0.072), with a significantly higher NRS score (p = 0.033). Enteral nutrition predominated, while combined feeding was minimally used. All patients received energy and protein below the ICU’s protocol recommendation. The proportion of days with fasting was 10.8%, being significantly higher in non-survivors (2 versus 3 days; p = 0.038). Higher protein delivery was associated with an increase in prealbumin over time (r2 = 0.19, p = 0.027). Conclusions: High NRS scores may identify patients at highest risk of poor outcome when exposed to underfeeding. Further studies are required to evaluate a nutrition strategy for patients with high NRS, addressing combined parenteral nutrition and protein delivery.
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Affiliation(s)
- Marina V Viana
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Geraldine Bagnoud
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Arianne Martinez
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Eva Favre
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Mélanie Charrière
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Doris Favre
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Philippe Eckert
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Mette M Berger
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland.
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Patient and Family Centered Actionable Processes of Care and Performance Measures for Persistent and Chronic Critical Illness: A Systematic Review. Crit Care Explor 2019; 1:e0005. [PMID: 32166252 PMCID: PMC7063874 DOI: 10.1097/cce.0000000000000005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Supplemental Digital Content is available in the text. To identify actionable processes of care, quality indicators, or performance measures and their evidence base relevant to patients with persistent or chronic critical illness and their family members including themes relating to patient/family experience.
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32
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Wintermann GB, Petrowski K, Weidner K, Strauß B, Rosendahl J. Impact of post-traumatic stress symptoms on the health-related quality of life in a cohort study with chronically critically ill patients and their partners: age matters. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:39. [PMID: 30736830 PMCID: PMC6368748 DOI: 10.1186/s13054-019-2321-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/11/2019] [Indexed: 12/25/2022]
Abstract
Background Survivors of an acute critical illness with continuing organ dysfunction and uncontrolled inflammatory responses are prone to become chronically critically ill. As mental sequelae, a post-traumatic stress disorder and an associated decrease in the health-related quality of life (QoL) may occur, not only in the patients but also in their partners. Currently, research on long-term mental distress in chronically critically ill patient-partner dyads, using appropriate dyadic analysis strategies (patients and partners being measured and linked on the same variables) and controlling for contextual factors, is lacking. Methods The present study investigates the interdependence of post-traumatic stress symptoms (PTSS) and the health-related QoL in n = 70 dyads of chronically critically ill patients and their partners, using the Actor-Partner-Interdependence Model (APIM) under consideration of contextual factors (age, gender, length of partnership). The Post-traumatic Stress Scale (PTSS-10) and Euro-Quality of Life (EQ-5D-3L) were applied in both the patients and their partners, within up to 6 months after the transfer from acute care ICU to post-acute ICU. Results Clinically relevant post-traumatic stress symptoms were reported by 17.1% of the patients and 18.6% of the partners. Both the chronically critically ill patients and their partners with more severe post-traumatic stress symptoms also showed a decreased health-related QoL. The latter was more pronounced in male partners compared to female partners or female patients. In younger partners (≤ 57 years), higher values of post-traumatic stress symptoms were associated with a decreased QoL in the patients. Conclusions Mental health screening and psychotherapeutic treatment options should be offered to both the chronically critically ill patients and their partners. Future research is required to address the special needs of younger patient-partner dyads, following protracted ICU treatment. Trial registration German Clinical Trials Register No. DRKS00003386. Registered 13 November 2011 Electronic supplementary material The online version of this article (10.1186/s13054-019-2321-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gloria-Beatrice Wintermann
- Department of Psychotherapy and Psychosomatic Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, 01307, Dresden, Germany.
| | - Katja Petrowski
- Department of Psychotherapy and Psychosomatic Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, 01307, Dresden, Germany.,Institute of Medical Psychology and Medical Sociology, Clinic and Polyclinic for Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Kerstin Weidner
- Department of Psychotherapy and Psychosomatic Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, 01307, Dresden, Germany
| | - Bernhard Strauß
- Institute of Psychosocial Medicine and Psychotherapy, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Jenny Rosendahl
- Institute of Psychosocial Medicine and Psychotherapy, Jena University Hospital, Friedrich-Schiller University, Jena, Germany.,Center for Sepsis Control and Care, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
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Abstract
Management of limited health-care resources has been of growing concern. Stewardship of health-care dollars and avoidance of low-value care is being increasingly recognized as a matter that affects all practitioners. This review aims to examine a particular pathological state with multifactorial origins: chronic critical illness (CCI). This condition exerts a large toll on society as well as individual patients and their families. Here, we offer a brief review as to the incidence/prevalence of CCI and suggestions for prevention. Emphasis should be placed on the importance of early, open communication among physicians and patients about their end-of-life decisions and advanced directives, so that decisions can be made wisely and with the patient's best interests in mind.
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Affiliation(s)
| | - William McGee
- 1 Baystate Medical Center, Springfield, MA, USA.,2 University of Massachusetts Medical School, Worcester, MA, USA
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