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Sikora A, Keats K, Murphy DJ, Devlin JW, Smith SE, Murray B, Buckley MS, Rowe S, Coppiano L, Kamaleswaran R. A common data model for the standardization of intensive care unit medication features. JAMIA Open 2024; 7:ooae033. [PMID: 38699649 PMCID: PMC11064096 DOI: 10.1093/jamiaopen/ooae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/12/2024] [Accepted: 04/09/2024] [Indexed: 05/05/2024] Open
Abstract
Objective Common data models provide a standard means of describing data for artificial intelligence (AI) applications, but this process has never been undertaken for medications used in the intensive care unit (ICU). We sought to develop a common data model (CDM) for ICU medications to standardize the medication features needed to support future ICU AI efforts. Materials and Methods A 9-member, multi-professional team of ICU clinicians and AI experts conducted a 5-round modified Delphi process employing conference calls, web-based communication, and electronic surveys to define the most important medication features for AI efforts. Candidate ICU medication features were generated through group discussion and then independently scored by each team member based on relevance to ICU clinical decision-making and feasibility for collection and coding. A key consideration was to ensure the final ontology both distinguished unique medications and met Findable, Accessible, Interoperable, and Reusable (FAIR) guiding principles. Results Using a list of 889 ICU medications, the team initially generated 106 different medication features, and 71 were ranked as being core features for the CDM. Through this process, 106 medication features were assigned to 2 key feature domains: drug product-related (n = 43) and clinical practice-related (n = 63). Each feature included a standardized definition and suggested response values housed in the electronic data library. This CDM for ICU medications is available online. Conclusion The CDM for ICU medications represents an important first step for the research community focused on exploring how AI can improve patient outcomes and will require ongoing engagement and refinement.
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Affiliation(s)
- Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA 30912, United States
| | - Kelli Keats
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA 30912, United States
| | - David J Murphy
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA 30322, United States
| | - John W Devlin
- Northeastern University School of Pharmacy, Boston, MA 02115, United States
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA 30601, United States
| | - Brian Murray
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC 27514, United States
| | - Mitchell S Buckley
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, AZ 85032, United States
| | - Sandra Rowe
- Department of Pharmacy, Oregon Health and Science University, Portland, OR 97239, United States
| | - Lindsey Coppiano
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA 30322, United States
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30322, United States
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA 30322, United States
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30322, United States
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Agnello L, Ciaccio AM, Del Ben F, Lo Sasso B, Biundo G, Giglia A, Giglio RV, Cortegiani A, Gambino CM, Ciaccio M. Monocyte distribution width (MDW) kinetic for monitoring sepsis in intensive care unit. Diagnosis (Berl) 2024; 0:dx-2024-0019. [PMID: 38644729 DOI: 10.1515/dx-2024-0019] [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: 01/23/2024] [Accepted: 04/08/2024] [Indexed: 04/23/2024]
Abstract
OBJECTIVES Monocyte distribution width (MDW) is a measure of monocyte anisocytosis. In this study, we assessed the role of MDW, in comparison to C-reactive protein (CRP), procalcitonin (PCT), and lactate, as a screening and prognostic biomarker of sepsis in intensive care unit (ICU) by longitudinally measuring it in the first 5 days of hospital stay. METHODS We considered all consecutive patients admitted to the ICU. At admission, patients were classified as septic or not according to Sepsis-3 criteria. MDW, CRP, PCT, and lactate were measured daily in the first 5 days of hospitalization. ICU mortality was also recorded. RESULTS We included 193 patients, 62 with sepsis and 131 without sepsis (controls). 58% and 26 % of the patients, with and without sepsis respectively, died during ICU stay. MDW showed the highest accuracy for sepsis detection, superior to CRP, PCT, and lactate (AUC of 0.840, 0.755, 0.708, 0.622, respectively). At admission, no biomarker predicts ICU mortality in patients with sepsis. The kinetic of all biomarkers during the first 5 days of hospitalization was associated with ICU mortality. Noteworthy, above all, the kinetic of MDW showed the best accuracy. Specifically, an increase or decrease in MDW from day 1-4 and 5 was significantly associated with mortality or survival, respectively. CONCLUSIONS MDW is a reliable diagnostic and prognostic sepsis biomarker, better than traditional biomarkers.
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Affiliation(s)
- Luisa Agnello
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, 18998 University of Palermo Palermo, Italy
| | - Anna Maria Ciaccio
- Internal Medicine and Medical Specialties "G. D'Alessandro", Department of Health Promotion, Maternal and Infant Care, University of Palermo, Palermo, Italy
| | - Fabio Del Ben
- Immunopathology and Cancer Biomakers, Department of Cancer Research and Advanced Diagnostics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Bruna Lo Sasso
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, 18998 University of Palermo Palermo, Italy
- Department of Laboratory Medicine, University Hospital "P. Giaccone" Palermo, Italy
| | - Giuseppe Biundo
- Department of Laboratory Medicine, University Hospital "P. Giaccone" Palermo, Italy
| | - Aurora Giglia
- Department of Laboratory Medicine, University Hospital "P. Giaccone" Palermo, Italy
| | - Rosaria Vincenza Giglio
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, 18998 University of Palermo Palermo, Italy
- Department of Laboratory Medicine, University Hospital "P. Giaccone" Palermo, Italy
| | - Andrea Cortegiani
- Department of Anesthesia, Intensive Care, and Emergency, Policlinico Paolo Giaccone, 18998 University of Palermo , Palermo, Italy
| | - Caterina Maria Gambino
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, 18998 University of Palermo Palermo, Italy
- Department of Laboratory Medicine, University Hospital "P. Giaccone" Palermo, Italy
| | - Marcello Ciaccio
- Department of Biomedicine, Neurosciences and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, 18998 University of Palermo Palermo, Italy
- Department of Laboratory Medicine, University Hospital "P. Giaccone" Palermo, Italy
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3
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Jeon Y, Kim S, Ahn S, Park JH, Cho H, Moon S, Lee S. Predicting septic shock in patients with sepsis at emergency department triage using systolic and diastolic shock index. Am J Emerg Med 2024; 78:196-201. [PMID: 38301370 DOI: 10.1016/j.ajem.2024.01.029] [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: 07/11/2023] [Revised: 12/19/2023] [Accepted: 01/15/2024] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION Identifying patients with at a high risk of progressing to septic shock is essential. Due to systemic vasodilation in the pathophysiology of septic shock, the use of diastolic blood pressure (DBP) has emerged. We hypothesized that the initial shock index (SI) and diastolic SI (DSI) at the emergency department (ED) triage can predict septic shock. METHOD This observational study used the prospectively collected sepsis registry. The primary outcome was progression to septic shock. Secondary outcomes were the time to vasopressor requirement, vasopressor dose, and severity according to SI and DSI. Patients were classified by tertiles according to the first principal component of shock index and diastolic shock index. RESULTS A total of 1267 patients were included in the analysis. The area under the receiver operating characteristic curve (AUC) for predicting progression to septic shock for DSI was 0.717, while that for SI was 0.707. The AUC for predicting progression to septic shock for DSI and SI were significantly higher than those for conventional early warning scores. Middle tertile showed adjusted Odd ratio (aOR) of 1.448 (95% CI 1.074-1.953), and that of upper tertile showed 3.704 (95% CI 2.299-4.111). CONCLUSION The SI and DSI were significant predictors of progression to septic shock. Our findings suggest an association between DSI and vasopressor requirement. We propose stratifying lower tertile as being at low risk, middle tertile as being at intermediate risk, and upper tertile as being at high risk of progression to septic shock. This system can be applied simply at the ED triage.
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Affiliation(s)
- Yumin Jeon
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Sungjin Kim
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Sejoong Ahn
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Jong-Hak Park
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Hanjin Cho
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Sungwoo Moon
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea
| | - Sukyo Lee
- Department of Emergency Medicine, Korea University Ansan Hospital, 15355, Ansan-si, Republic of Korea.
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Bode C, Weis S, Sauer A, Wendel-Garcia P, David S. Targeting the host response in sepsis: current approaches and future evidence. Crit Care 2023; 27:478. [PMID: 38057824 PMCID: PMC10698949 DOI: 10.1186/s13054-023-04762-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023] Open
Abstract
Sepsis, a dysregulated host response to infection characterized by organ failure, is one of the leading causes of death worldwide. Disbalances of the immune response play an important role in its pathophysiology. Patients may develop simultaneously or concomitantly states of systemic or local hyperinflammation and immunosuppression. Although a variety of effective immunomodulatory treatments are generally available, attempts to inhibit or stimulate the immune system in sepsis have failed so far to improve patients' outcome. The underlying reason is likely multifaceted including failure to identify responders to a specific immune intervention and the complex pathophysiology of organ dysfunction that is not exclusively caused by immunopathology but also includes dysfunction of the coagulation system, parenchymal organs, and the endothelium. Increasing evidence suggests that stratification of the heterogeneous population of septic patients with consideration of their host response might led to treatments that are more effective. The purpose of this review is to provide an overview of current studies aimed at optimizing the many facets of host response and to discuss future perspectives for precision medicine approaches in sepsis.
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Affiliation(s)
- Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Sebastian Weis
- Institute for Infectious Disease and Infection Control, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
- Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll Institute-HKI, Jena, Germany
| | - Andrea Sauer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Pedro Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
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5
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Alderden JG, Johnny JD. Artificial Intelligence and the Critical Care Nurse. Crit Care Nurse 2023; 43:7-8. [PMID: 37777243 DOI: 10.4037/ccn2023755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
- Jenny G Alderden
- Jenny G. Alderden is an associate professor, School of Nursing, Boise State University, Idaho
| | - Jace D Johnny
- Jace D. Johnny is a nurse practitioner, Pulmonary and Critical Care Division at University of Utah Health, Salt Lake City, Utah
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Sikora A, Jeong H, Yu M, Chen X, Murray B, Kamaleswaran R. Cluster analysis driven by unsupervised latent feature learning of medications to identify novel pharmacophenotypes of critically ill patients. Sci Rep 2023; 13:15562. [PMID: 37730817 PMCID: PMC10511715 DOI: 10.1038/s41598-023-42657-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/13/2023] [Indexed: 09/22/2023] Open
Abstract
Unsupervised clustering of intensive care unit (ICU) medications may identify unique medication clusters (i.e., pharmacophenotypes) in critically ill adults. We performed an unsupervised analysis with Restricted Boltzmann Machine of 991 medications profiles of patients managed in the ICU to explore pharmacophenotypes that correlated with ICU complications (e.g., mechanical ventilation) and patient-centered outcomes (e.g., length of stay, mortality). Six unique pharmacophenotypes were observed, with unique medication profiles and clinically relevant differences in ICU complications and patient-centered outcomes. While pharmacophenotypes 2 and 4 had no statistically significant difference in ICU length of stay, duration of mechanical ventilation, or duration of vasopressor use, their mortality differed significantly (9.0% vs. 21.9%, p < 0.0001). Pharmacophenotype 4 had a mortality rate of 21.9%, compared with the rest of the pharmacophenotypes ranging from 2.5 to 9%. Phenotyping approaches have shown promise in classifying the heterogenous syndromes of critical illness to predict treatment response and guide clinical decision support systems but have never included comprehensive medication information. This first-ever machine learning approach revealed differences among empirically-derived subgroups of ICU patients that are not typically revealed by traditional classifiers. Identification of pharmacophenotypes may enable enhanced decision making to optimize treatment decisions.
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Affiliation(s)
- Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA.
| | | | - Mengyun Yu
- Department of Statistics, University of Georgia Franklin College of Arts and Sciences, Athens, USA
| | - Xianyan Chen
- Department of Statistics, University of Georgia Franklin College of Arts and Sciences, Athens, USA
| | - Brian Murray
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA, USA
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
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Sikora A, Rafiei A, Rad MG, Keats K, Smith SE, Devlin JW, Murphy DJ, Murray B, Kamaleswaran R. Pharmacophenotype identification of intensive care unit medications using unsupervised cluster analysis of the ICURx common data model. Crit Care 2023; 27:167. [PMID: 37131200 PMCID: PMC10155304 DOI: 10.1186/s13054-023-04437-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/10/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Identifying patterns within ICU medication regimens may help artificial intelligence algorithms to better predict patient outcomes; however, machine learning methods incorporating medications require further development, including standardized terminology. The Common Data Model for Intensive Care Unit (ICU) Medications (CDM-ICURx) may provide important infrastructure to clinicians and researchers to support artificial intelligence analysis of medication-related outcomes and healthcare costs. Using an unsupervised cluster analysis approach in combination with this common data model, the objective of this evaluation was to identify novel patterns of medication clusters (termed 'pharmacophenotypes') correlated with ICU adverse events (e.g., fluid overload) and patient-centered outcomes (e.g., mortality). METHODS This was a retrospective, observational cohort study of 991 critically ill adults. To identify pharmacophenotypes, unsupervised machine learning analysis with automated feature learning using restricted Boltzmann machine and hierarchical clustering was performed on the medication administration records of each patient during the first 24 h of their ICU stay. Hierarchical agglomerative clustering was applied to identify unique patient clusters. Distributions of medications across pharmacophenotypes were described, and differences among patient clusters were compared using signed rank tests and Fisher's exact tests, as appropriate. RESULTS A total of 30,550 medication orders for the 991 patients were analyzed; five unique patient clusters and six unique pharmacophenotypes were identified. For patient outcomes, compared to patients in Clusters 1 and 3, patients in Cluster 5 had a significantly shorter duration of mechanical ventilation and ICU length of stay (p < 0.05); for medications, Cluster 5 had a higher distribution of Pharmacophenotype 1 and a smaller distribution of Pharmacophenotype 2, compared to Clusters 1 and 3. For outcomes, patients in Cluster 2, despite having the highest severity of illness and greatest medication regimen complexity, had the lowest overall mortality; for medications, Cluster 2 also had a comparably higher distribution of Pharmacophenotype 6. CONCLUSION The results of this evaluation suggest that patterns among patient clusters and medication regimens may be observed using empiric methods of unsupervised machine learning in combination with a common data model. These results have potential because while phenotyping approaches have been used to classify heterogenous syndromes in critical illness to better define treatment response, the entire medication administration record has not been incorporated in those analyses. Applying knowledge of these patterns at the bedside requires further algorithm development and clinical application but may have the future potential to be leveraged in guiding medication-related decision making to improve treatment outcomes.
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Affiliation(s)
- Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA USA
| | - Alireza Rafiei
- Department of Computer Science and Informatics, Emory University, Atlanta, GA USA
| | - Milad Ghiasi Rad
- Department of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA USA
| | - Kelli Keats
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA USA
| | - Susan E. Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA USA
| | - John W. Devlin
- Northeastern University School of Pharmacy, Boston, MA USA
- Brigham and Women’s Hospital, Division of Pulmonary and Critical Care Medicine, Boston, MA USA
| | - David J. Murphy
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA USA
| | - Brian Murray
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA USA
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA USA
| | - MRC-ICU Investigator Team
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA USA
- Department of Computer Science and Informatics, Emory University, Atlanta, GA USA
- Department of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA USA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA USA
- Northeastern University School of Pharmacy, Boston, MA USA
- Brigham and Women’s Hospital, Division of Pulmonary and Critical Care Medicine, Boston, MA USA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA USA
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC USA
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA USA
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA USA
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8
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Komorowski M, Green A, Tatham KC, Seymour C, Antcliffe D. Sepsis biomarkers and diagnostic tools with a focus on machine learning. EBioMedicine 2022; 86:104394. [PMID: 36470834 PMCID: PMC9783125 DOI: 10.1016/j.ebiom.2022.104394] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 12/04/2022] Open
Abstract
Over the last years, there have been advances in the use of data-driven techniques to improve the definition, early recognition, subtypes characterisation, prognostication and treatment personalisation of sepsis. Some of those involve the discovery or evaluation of biomarkers or digital signatures of sepsis or sepsis sub-phenotypes. It is hoped that their identification may improve timeliness and accuracy of diagnosis, suggest physiological pathways and therapeutic targets, inform targeted recruitment into clinical trials, and optimise clinical management. Given the complexities of the sepsis response, panels of biomarkers or models combining biomarkers and clinical data are necessary, as well as specific data analysis methods, which broadly fall under the scope of machine learning. This narrative review gives a brief overview of the main machine learning techniques (mainly in the realms of supervised and unsupervised methods) and published applications that have been used to create sepsis diagnostic tools and identify biomarkers.
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Affiliation(s)
- Matthieu Komorowski
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, SW7 2AZ, United Kingdom,Corresponding author.
| | - Ashleigh Green
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Kate C. Tatham
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, SW7 2AZ, United Kingdom,Anaesthetics, Perioperative Medicine and Pain Department, Royal Marsden NHS Foundation Trust, 203 Fulham Rd, London, SW3 6JJ, United Kingdom
| | - Christopher Seymour
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Antcliffe
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, SW7 2AZ, United Kingdom
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Ward MA, Kuttab HI, Tuck N, Taleb A, Okut H, Badgett RG. The Effect of Fluid Initiation Timing on Sepsis Mortality: A Meta-Analysis. J Intensive Care Med 2022; 37:1504-1511. [PMID: 35946105 DOI: 10.1177/08850666221118513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Current guidelines suggest the immediate initiation of crystalloid for sepsis-induced hypoperfusion but note that supporting evidence is low quality. The aim of this study is to examine the effect of timing of fluid initiation on mortality for adults with sepsis. DATA SOURCES Two authors independently reviewed relevant articles and extracted study details from PubMed, Scopus, Cochrane, Google Scholar, and previous relevant systematic reviews from 1-1-2000 to 1-6-2022. Registered with PROSPERO (CRD42021245431) and bias assessed using CLARITY. STUDY SELECTION A minimum of severe sepsis (Sepsis-2) or sepsis (Sepsis-3) for patients ≥18 years old. Fluid initiation timing ranging from prehospital to 120 min within sepsis onset defined as "early" initiation. DATA EXTRACTION Included studies providing mortality-based odds ratios (or comparable) adjusting for confounders or prospective trials. DATA SYNTHESIS From 1643 citations, five retrospective cohort studies were included (n = 20,209) with in-hospital mortality of 21.8%. A pooled analysis (odds ratio = OR [95% CI]) did not observe an impact on mortality for the early initiation of fluids among all patients, OR = 0.79 [0.62-1.02]; heterogeneity: I2 = 86% [70-94%], but when studies analyzed cases of hypotension where available, a survival benefit was observed, OR = 0.74 [0.61-0.90]. Initiation of fluids in two prehospital studies did not impact mortality, OR = 0.82 [0.27-2.43]. However, both prehospital cohorts observed benefit among hypotensive patients individually, although heterogenous results precluded significance when pooled, OR = 0.50 [0.21-1.18]. Three hospital-based studies with initiation stratified at 30, 100, and 120 min, observed survival benefit both individually and when pooled, OR = 0.78 [0.63-0.97]. No differences were observed between prehospital versus hospital subgroups. CONCLUSION This meta-analysis supports the guideline recommendations for early fluid initiation once sepsis is recognized, especially in cases of hypotension. Findings are limited by the small number, heterogeneity, and retrospective nature of available studies. Further retrospective investigations may be worthwhile as randomized studies on fluid initiation are unlikely.
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Affiliation(s)
- Michael A Ward
- Department of Emergency, 5232University of Wisconsin-Madison, Madison, WI, USA
| | - Hani I Kuttab
- Department of Emergency, 5232University of Wisconsin-Madison, Madison, WI, USA
| | - Nicholas Tuck
- Department of Internal Medicine, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Ali Taleb
- Department of Internal Medicine, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Hayrettin Okut
- Office of Research, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Robert G Badgett
- Department of Internal Medicine, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
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10
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Abstract
Despite its heterogeneous phenotypes, sepsis or life-threatening dysfunction in response to infection is often treated empirically. Identifying patient subgroups with unique pathophysiology and treatment response is critical to the advancement of sepsis care. However, phenotyping methods and results are as heterogeneous as the disease itself. This scoping review evaluates the prognostic capabilities and treatment implications of adult sepsis and septic shock phenotyping methods. DATA SOURCES Medline and Embase. STUDY SELECTION We included clinical studies that described sepsis or septic shock and used any clustering method to identify sepsis phenotypes. We excluded conference abstracts, literature reviews, comments, letters to the editor, and in vitro studies. We assessed study quality using a validated risk of bias tool for observational cohort and cross-sectional studies. DATA EXTRACTION We extracted population, methodology, validation, and phenotyping characteristics from 17 studies. DATA SYNTHESIS Sepsis phenotyping methods most frequently grouped patients based on the degree of inflammatory response and coagulopathy using clinical, nongenomic variables. Five articles clustered patients based on genomic or transcriptomic data. Seven articles generated patient subgroups with differential response to sepsis treatments. Cluster clinical characteristics and their associations with mortality and treatment response were heterogeneous across studies, and validity was evaluated in nine of 17 articles, hindering pooled analysis of results and derivation of universal truths regarding sepsis phenotypes, their prognostic capabilities, and their associations with treatment response. CONCLUSIONS Sepsis phenotyping methods can identify high-risk patients and those with high probability of responding well to targeted treatments. Research quality was fair, but achieving generalizability and clinical impact of sepsis phenotyping will require external validation and direct comparison with alternative approaches.
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11
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Orso D. The "one-size-fits-all" management of sepsis is a dismissal of clinical judgment. Eur J Emerg Med 2022; 29:12-13. [PMID: 34932029 DOI: 10.1097/mej.0000000000000893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Daniele Orso
- Department of Medical Sciences (DAME), University of Udine, Italy
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Italy
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12
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Ma P, Liu J, Shen F, Liao X, Xiu M, Zhao H, Zhao M, Xie J, Wang P, Huang M, Li T, Duan M, Qian K, Peng Y, Zhou F, Xin X, Wan X, Wang Z, Li S, Han J, Li Z, Ding G, Deng Q, Zhang J, Zhu Y, Ma W, Wang J, Kang Y, Zhang Z. Individualized resuscitation strategy for septic shock formalized by finite mixture modeling and dynamic treatment regimen. Crit Care 2021; 25:243. [PMID: 34253228 PMCID: PMC8273991 DOI: 10.1186/s13054-021-03682-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/06/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Septic shock comprises a heterogeneous population, and individualized resuscitation strategy is of vital importance. The study aimed to identify subclasses of septic shock with non-supervised learning algorithms, so as to tailor resuscitation strategy for each class. METHODS Patients with septic shock in 25 tertiary care teaching hospitals in China from January 2016 to December 2017 were enrolled in the study. Clinical and laboratory variables were collected on days 0, 1, 2, 3 and 7 after ICU admission. Subclasses of septic shock were identified by both finite mixture modeling and K-means clustering. Individualized fluid volume and norepinephrine dose were estimated using dynamic treatment regime (DTR) model to optimize the final mortality outcome. DTR models were validated in the eICU Collaborative Research Database (eICU-CRD) dataset. RESULTS A total of 1437 patients with a mortality rate of 29% were included for analysis. The finite mixture modeling and K-means clustering robustly identified five classes of septic shock. Class 1 (baseline class) accounted for the majority of patients over all days; class 2 (critical class) had the highest severity of illness; class 3 (renal dysfunction) was characterized by renal dysfunction; class 4 (respiratory failure class) was characterized by respiratory failure; and class 5 (mild class) was characterized by the lowest mortality rate (21%). The optimal fluid infusion followed the resuscitation/de-resuscitation phases with initial large volume infusion and late restricted volume infusion. While class 1 transitioned to de-resuscitation phase on day 3, class 3 transitioned on day 1. Classes 1 and 3 might benefit from early use of norepinephrine, and class 2 can benefit from delayed use of norepinephrine while waiting for adequate fluid infusion. CONCLUSIONS Septic shock comprises a heterogeneous population that can be robustly classified into five phenotypes. These classes can be easily identified with routine clinical variables and can help to tailor resuscitation strategy in the context of precise medicine.
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Affiliation(s)
- Penglin Ma
- Department of Critical Care Medicine, Guiqian International General Hospital, Guiyang, People's Republic of China
| | - Jingtao Liu
- Department of Critical Care Medicine, The 8th Medical Center of Chinese, PLA General Hospital, Beijing, 100091, People's Republic of China
| | - Feng Shen
- Department of Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, People's Republic of China
| | - Xuelian Liao
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Ming Xiu
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, People's Republic of China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei General Hospital, Shijiazhuang, People's Republic of China
| | - Mingyan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Jing Xie
- General Intensive Care Unit Department, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Peng Wang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Man Huang
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University, Hangzhou, People's Republic of China
| | - Tong Li
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Meili Duan
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Kejian Qian
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Yue Peng
- Department of Critical Care Medicine, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Feihu Zhou
- Department of Critical Care Medicine, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Xin Xin
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xianyao Wan
- The First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - ZongYu Wang
- Department of Intensive Care, Peking University Third Hospital, Beijing, People's Republic of China
| | - Shusheng Li
- Department of Emergency, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jianwei Han
- Department of Critical Care Medicine, The 8th medical Center of Chinese, PLA General Hospital, Beijing, People's Republic of China
| | - Zhenliang Li
- Department of Critical Care, Beijing PingGu Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Guolei Ding
- Intensive Care Unit, The Hospital of Shunyi District, Beijing, People's Republic of China
| | - Qun Deng
- Department of Critical Care Medicine, The 4th Medical Center of Chinese, PLA General Hospital, Beijing, People's Republic of China
| | - Jicheng Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, People's Republic of China
| | - Yue Zhu
- Department of Critical Care, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wenjing Ma
- Department of Critical Care, Beijing Miyun Hospital, Beijing, People's Republic of China
| | - Jingwen Wang
- Intensive Care Unit, Beijing Changping District Hospital, Beijing, People's Republic of China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, People's Republic of China.
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Abstract
Objectives Sepsis and septic shock are leading causes of in-hospital mortality. Timely treatment is crucial in improving patient outcome, yet treatment delays remain common. Early prediction of those patients with sepsis who will progress to its most severe form, septic shock, can increase the actionable window for interventions. We aim to extend a time-evolving risk score, previously developed in adult patients, to predict pediatric sepsis patients who are likely to develop septic shock before its onset, and to determine whether or not these risk scores stratify into groups with distinct temporal evolution once this prediction is made. Design Retrospective cohort study. Setting Academic medical center from July 1, 2016, to December 11, 2020. Patients Six-thousand one-hundred sixty-one patients under 18 admitted to the Johns Hopkins Hospital PICU. Interventions None. Measurements and Main Results We trained risk models to predict impending transition into septic shock and compute time-evolving risk scores representative of a patient's probability of developing septic shock. We obtain early prediction performance of 0.90 area under the receiver operating curve, 43% overall positive predictive value, patient-specific positive predictive value as high as 62%, and an 8.9-hour median early warning time using Sepsis-3 labels based on age-adjusted Sequential Organ Failure Assessment score. Using spectral clustering, we stratified pediatric sepsis patients into two clusters differing in septic shock prevalence, mortality, and proportion of patients adequately fluid resuscitated. CONCLUSIONS We demonstrate the applicability of our methodology for early prediction and stratification for risk of septic shock in pediatric sepsis patients. Through analyses of risk score evolution over time, we corroborate our past finding of an abrupt transition preceding onset of septic shock in children and are able to stratify pediatric sepsis patients using their risk score trajectories into low and high-risk categories.
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