Prognosis of mechanically ventilated patients with COVID-19 after failure of high-flow nasal cannula: a retrospective cohort study

BACKGROUND

There is an argument whether the delayed intubation aggravate the respiratory failure in Acute respiratory distress syndrome (ARDS) patients with coronavirus disease 2019 (COVID-19). We aimed to investigate the effect of high-flow nasal cannula (HFNC) failure before mechanical ventilation on clinical outcomes in mechanically ventilated patients with COVID-19.

METHODS

This retrospective cohort study included mechanically ventilated patients who were diagnosed with COVID-19 and admitted to the intensive care unit (ICU) between February 2020 and December 2021 at Asan Medical Center. The patients were divided into HFNC failure (HFNC-F) and mechanical ventilation (MV) groups according to the use of HFNC before MV. The primary outcome of this study was to compare the worst values of ventilator parameters from day 1 to day 3 after mechanical ventilation between the two groups.

RESULTS

Overall, 158 mechanically ventilated patients with COVID-19 were included in this study: 107 patients (67.7%) in the HFNC-F group and 51 (32.3%) in the MV group. The two groups had similar profiles of ventilator parameter from day 1 to day 3 after mechanical ventilation, except of dynamic compliance on day 3 (28.38 mL/cmH2O in MV vs. 30.67 mL/H2O in HFNC-F, p = 0.032). In addition, the HFNC-F group (5.6%) had a lower rate of ECMO at 28 days than the MV group (17.6%), even after adjustment (adjusted hazard ratio, 0.30; 95% confidence interval, 0.11-0.83; p = 0.045).

CONCLUSIONS

Among mechanically ventilated COVID-19 patients, HFNC failure before mechanical ventilation was not associated with deterioration of respiratory failure.

Age distribution and clinical results of critically ill patients above 65-year-old in an aging society: A retrospective cohort study

Background

Increasing age has been observed among patients admitted to the intensive care unit(ICU). Age traditionally considered a risk factor for ICU mortality. We investigated how the epidemiology and clinical outcomes of older ICU patients have changed over a decade.

Methods

We analyzed patients admitted to the ICU at a university hospital in Seoul, South Korea. We defined patients aged 65 and older as older patients. Changes in age groups and mortality risk factors over the study period were analyzed.

Results

A total of 32,322 patients were enrolled who aged ≥ 65 years admitted to the ICUs between January 1, 2007, and December 31, 2017. Patients aged 65 years accounted for 35% and of these, the older(O: 65-74 yrs) comprised 19,630(66.5%), very older(VO: 75-84 yrs) group 8,573(29.1%), and very very older(VVO: 85 years) group 1,300(4.4 %). The mean age of ICU patients over the study period increased(71.9±5.6yrs in 2007 vs. 73.2±6.1yrs in 2017) and the proportions of the VO and VVO group both increased. Over the period, the proportion of female increased(37.9% in 2007 vs. 43.3% in 2017), and increased ICU admissions for medical reasons(39.7% in 2007 vs. 40.2% in 2017). In-hospital mortality declined across all older age groups, from 10.3% in 2007 to 7.6% in 2017. Hospital length of stay(LOS) decreased in all groups, but ICU LOS decreased only in the O and VO groups.

Conclusion

The study indicates a changing demographic in ICUs with an increase in older patients, and suggests a need for customized ICU treatment strategies and resources.

Highly secreted tryptophanyl tRNA synthetase 1 as a potential theranostic target for hypercytokinemic severe sepsis

Despite intensive clinical and scientific efforts, the mortality rate of sepsis remains high due to the lack of precise biomarkers for patient stratification and therapeutic guidance. Secreted human tryptophanyl-tRNA synthetase 1 (WARS1), an endogenous ligand for Toll-like receptor (TLR) 2 and TLR4 against infection, activates the genes that signify the hyperinflammatory sepsis phenotype. High plasma WARS1 levels stratified the early death of critically ill patients with sepsis, along with elevated levels of cytokines, chemokines, and lactate, as well as increased numbers of absolute neutrophils and monocytes, and higher Sequential Organ Failure Assessment (SOFA) scores. These symptoms were recapitulated in severely ill septic mice with hypercytokinemia. Further, injection of WARS1 into mildly septic mice worsened morbidity and mortality. We created an anti-human WARS1-neutralizing antibody that suppresses proinflammatory cytokine expression in marmosets with endotoxemia. Administration of this antibody into severe septic mice attenuated cytokine storm, organ failure, and early mortality. With antibiotics, the antibody almost completely prevented fatalities. These data imply that blood-circulating WARS1-guided anti-WARS1 therapy may provide a novel theranostic strategy for life-threatening systemic hyperinflammatory sepsis.

Clinical impact of pre-existing acute exacerbation in patients with interstitial lung disease who underwent lung transplantation

BACKGROUND

Acute exacerbation of interstitial lung disease (AE-ILD) significantly impacts prognosis, leading to high mortality rates. Although lung transplantation is a life-saving treatment for selected patients with ILD, its outcomes in those presenting with AE-ILD have yielded conflicting results compared with those with stable ILD. This study aims to investigate the impact of pre-existing AE on the prognosis of ILD patients who underwent lung transplantation.

METHOD

We conducted a single-center retrospective study by reviewing the medical records of 108 patients who underwent lung transplantation for predisposing ILD at Asan Medical Center, Seoul, South Korea, between 2008 and 2022. The primary objective was to compare the survival of patients with AE-ILD at the time of transplantation with those without AE-ILD.

RESULTS

Among the 108 patients, 52 (48.1%) experienced AE-ILD at the time of lung transplantation, and 81 (75.0%) required pre-transplant mechanical ventilation. Although the type of ILD (IPF vs. non-IPF ILD) did not affect clinical outcomes after transplantation, AE-ILD was associated with worse survival outcomes. The survival probabilities at 90 days, 1 year, and 3 years post-transplant for patients with AE-ILD were 86.5%, 73.1%, and 60.1%, respectively, while those for patients without AE-ILD were higher, at 92.9%, 83.9%, and 79.6% (p = 0.032). In the multivariable analysis, pre-existing AE was an independent prognostic factor for mortality in ILD patients who underwent lung transplantation.

CONCLUSIONS

Although lung transplantation remains an effective treatment option for ILD patients with pre-existing AE, careful consideration is needed, especially in patients requiring pre-transplant mechanical respiratory support.

Impact of a cumulative positive fluid balance during the first three ICU days in patients with sepsis: a propensity score-matched cohort study

BACKGROUND

The optimal strategy for fluid management during the first few days of ICU in sepsis patients remains controversial. We aimed to investigate the impact of cumulative fluid balance during the first three days of ICU on the mortality of patients with sepsis.

METHODS

This study analyzed prospectively collected data from the Korean Sepsis Alliance Database, which registered 11,981 sepsis patients from 20 hospitals. We selected three propensity score-matched cohorts consisting of patients with a negative or positive cumulative fluid balance during the first three ICU days: from ICU admission to the first midnight as the D1 cohort, until the second midnight as the D2 cohort, and until the third midnight as the D3 cohort. The propensity score for fluid balance was calculated using covariates including the amount of fluid output during the first three ICU days. The primary outcome was mortality at day 28 in the ICU.

RESULTS

From a total of 11,981 patients, 2516 patients were included for propensity score matching. After matching in a 1:1 ratio, there were 483, 373, and 392 matched pairs of patients assigned to the D1, D2, and D3 cohorts, respectively. In the D1 cohort, there were no significant differences in mortality at day 28 (hazard ratio [HR], 1.17; 95% confidence interval [CI] 0.85-1.60; P = 0.354) between the two groups. The positive fluid groups in both the D2 (HR, 2.13; 95% CI 1.48-3.06; P < 0.001) and D3 (HR, 1.56; 95% CI 1.10-2.22; P = 0.012) cohorts had significantly higher mortality rates than the negative fluid groups.

CONCLUSIONS

In patients with sepsis, a positive fluid balance on the first ICU day was not associated with mortality at day 28. In contrast, cumulative positive fluid balances on the second and third ICU days were associated with higher mortality at day 28.

Extended Versus Intermittent Meropenem Infusion in the Treatment of Nosocomial Pneumonia: A Retrospective Single-Center Study

The efficacy of extended meropenem infusions in patients with nosocomial pneumonia is not well defined. Therefore, we compared the clinical outcomes of extended versus intermittent meropenem infusions in the treatment of nosocomial pneumonia. We performed a retrospective analysis of extended versus intermittent meropenem infusions in adult patients who had been treated for nosocomial pneumonia at a medical ICU between 1 May 2018 and 30 April 2020. The primary outcome was mortality at 14 days. Overall, 64 patients who underwent an extended infusion and 97 with an intermittent infusion were included in this study. At 14 days, 10 (15.6%) patients in the extended group and 22 (22.7%) in the intermittent group had died (adjusted hazard ratio (HR), 0.55; 95% confidence interval (CI): 0.23-1.31; p = 0.174). In the subgroup analysis, significant differences in mortality at day 14 were observed in patients following empirical treatment with meropenem (adjusted HR, 0.17; 95% CI: 0.03-0.96; p = 0.045) and in Gram-negative pathogens identified by blood or sputum cultures (adjusted HR, 0.01; 95% CI: 0.01-0.83; p = 0.033). Extended infusion of meropenem compared with intermittent infusion as a treatment option for nosocomial pneumonia may have a potential advantage in specific populations.

Contributed Session II: Immune cell speed changes over 5 orders of magnitude in response to inflammation in the retina

Inflammation in vascularized tissues is mediated by circulating immune cells that are recruited to damaged tissue. Immune cells undergo dramatic changes in speed and motility indicating the severity and staging of inflammation. Here, we characterize the spectrum of retinal leukocyte kinetics in response to an acute inflammatory stimulus using adaptive optics scanning light ophthalmoscopy (AOSLO) in living mice. C57BL/6J male mice were injected intravitreally with 1 µL lipopolysaccharide (LPS) and imaged at 6, 24 and 72 hours after LPS injection using phase contrast and fluorescence AOSLO. Speed of circulating leukocytes (n= 286 cells, 2 mice) was measured with 15kHz point-scan imaging using automated approach (Joseph et al. 2019). Rolling leukocytes (n=300 cells, 5 mice, 6 hrs after LPS) and extravasated cells (n=92 cells, 8 mice) were visualized with time-lapse imaging and manually tracked using ImageJ. Using our custom AOSLO, we observed leukocyte speeds spanning 5 orders of magnitude in the living retina. The fastest speeds were the circulating leukocytes (13,257.37 ± 7,086.41 µm/s). After LPS, leukocytes roll along the venular wall, where cell speed was 1000x slower (11.45 ± 7.45 µm/s.) When immune cells extravasated into the tissue, cell speed dropped further by 100x (0.3 ± 0.15 µm/s). Observed leukocyte speeds cluster around three distinct velocity bands that stratify the unique and purposeful behavior of these cells as they progress through the inflammatory cascade.

A targeted metabolomics approach for sepsis-induced ARDS and its subphenotypes

BACKGROUND

Acute respiratory distress syndrome (ARDS) is etiologically and clinically a heterogeneous disease. Its diagnostic characteristics and subtype classification, and the application of these features to treatment, have been of considerable interest. Metabolomics is becoming important for identifying ARDS biology and distinguishing its subtypes. This study aimed to identify metabolites that could distinguish sepsis-induced ARDS patients from non-ARDS controls, using a targeted metabolomics approach, and to identify whether sepsis-induced direct and sepsis-induced indirect ARDS are metabolically distinct groups, and if so, confirm their metabolites and associated pathways.

METHODS

This study retrospectively analyzed 54 samples of ARDS patients from a sepsis registry that was prospectively collected from March 2011 to February 2018, along with 30 non-ARDS controls. The cohort was divided into direct and indirect ARDS. Metabolite concentrations of five analyte classes (energy metabolism, free fatty acids, amino acids, phospholipids, sphingolipids) were measured using liquid chromatography-tandem mass spectrometry and gas chromatography-mass spectrometry by targeted metabolomics.

RESULTS

In total, 186 metabolites were detected. Among them, 102 metabolites could differentiate sepsis-induced ARDS patients from the non-ARDS controls, while 14 metabolites could discriminate sepsis-induced ARDS subphenotypes. Using partial least-squares discriminant analysis, we showed that sepsis-induced ARDS patients were metabolically distinct from the non-ARDS controls. The main distinguishing metabolites were lysophosphatidylethanolamine (lysoPE) plasmalogen, PE plasmalogens, and phosphatidylcholines (PCs). Sepsis-induced direct and indirect ARDS were also metabolically distinct subgroups, with differences in lysoPCs. Glycerophospholipid and sphingolipid metabolism were the most significant metabolic pathways involved in sepsis-induced ARDS biology and in sepsis-induced direct/indirect ARDS, respectively.

CONCLUSION

Our study demonstrated a marked difference in metabolic patterns between sepsis-induced ARDS patients and non-ARDS controls, and between sepsis-induced direct and indirect ARDS subpheonotypes. The identified metabolites and pathways can provide clues relevant to the diagnosis and treatment of individuals with ARDS.

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

Gut microbiota alterations in critically Ill patients with carbapenem-resistant Enterobacteriaceae colonization: A clinical analysis

Background

Carbapenem-resistant Enterobacteriaceae (CRE) are an emerging concern for global health and are associated with high morbidity and mortality in critically ill patients. Risk factors for CRE acquisition include broad-spectrum antibiotic use and microbiota dysbiosis in critically ill patients. Therefore, we evaluated the alteration of the intestinal microbiota associated with CRE colonization in critically ill patients.

Methods

Fecal samples of 41 patients who were diagnosed with septic shock or respiratory failure were collected after their admission to the intensive care unit (ICU). The gut microbiota profile determined using 16S rRNA gene sequencing and quantitative measurement of fecal short-chain fatty acids were evaluated in CRE-positive (n = 9) and CRE negative (n = 32) patients. The analysis of bacterial metabolic abundance to identify an association between CRE acquisition and metabolic pathway was performed.

Results

CRE carriers showed a significantly increased proportion of the phyla Proteobacteria and decreased numbers of the phyla Bacteroidetes as compared to the CRE non-carriers. Linear discriminant analysis (LDA) with linear discriminant effect size showed that the genera Erwinia, Citrobacter, Klebsiella, Cronobacter, Kluyvera, Dysgomonas, Pantoea, and Alistipes had an upper 2 LDA score in CRE carriers. The alpha-diversity indices were significantly decreased in CRE carriers, and beta-diversity analysis demonstrated that the two groups were clustered significantly apart. Among short-chain fatty acids, the levels of isobutyric acid and valeric acid were significantly decreased in CRE carriers. Furthermore, the PICRUSt-predicted metabolic pathways revealed significant differences in five features, including ATP-binding cassette transporters, phosphotransferase systems, sphingolipid metabolism, other glycan degradation, and microbial metabolism, in diverse environments between the two groups.

Conclusion

Critically ill patients with CRE have a distinctive gut microbiota composition and community structure, altered short-chain fatty acid production and changes in the metabolic pathways. Further studies are needed to determine whether amino acids supplementation improves microbiota dysbiosis in patients with CRE.

Epidemiology and characteristics of respiratory syncytial virus pneumonia in critically ill adults

Background

Severe RSV-associated pneumonia in adults has been rarely addressed. We investigated the burden and clinical characteristics of severe RSV-associated pneumonia in critically ill adult patients.

Methods

We analyzed a prospective cohort of 2,865 adults with severe pneumonia who were admitted to the intensive care unit in a 2,700-bed tertiary care hospital from 2010–2019. The epidemiology, characteristics, and outcomes of 92 cases of severe RSV-associated pneumonia and 163 cases of severe influenza virus (IFV)-associated pneumonia were compared.

Results

Of 1,589 cases of severe community-acquired pneumonia, the incidence of RSV-associated pneumonia was less than half that of IFV-associated pneumonia (3.4% vs. 8.1%). However, among 1,276 cases of severe hospital-acquired pneumonia (HAP), there were slightly more cases of RSV-associated than IFV-associated pneumonia (3.8% vs. 3.5%). During the nine epidemic seasons, RSV-A (five seasons) and RSV-B (four seasons) predominated alternately. Structural lung disease, diabetes mellitus, and malignancy were common underlying diseases in both groups. Immunocompromise (57.6% vs. 34.4%, p&lt;0.001) and hospital acquisition (47.8% vs. 23.9%, p&lt;0.001) were significantly more common in the RSV group. Co-infection with Streptococcus pneumoniae (3.3% vs. 9.8%, p=0.08) and methicillin-susceptible Staphylococcus aureus (1.1% vs. 6.8%, p=0.06) tended to be less frequent in the RSV group. The 90-day mortalities were high in both groups (39.1% vs. 40.5%, p=0.89).

Conclusion

RSV infection was associated with substantial morbidity and mortality in critically ill adult patients, similar to IFV. The relatively higher incidence of RSV in severe HAP suggests that the transmissibility of RSV can exceed that of IFV in a hospital setting.

1224. The incidence of severe C. striatum hospital-acquired pneumonia sharply increased and was associated with a high mortality rate

Background

The clinical information on patients with severe C. striatum pneumonia who require intensive care unit admission is currently limited.

Methods

We investigated the incidence and characteristics of severe Corynebacterium striatum pneumonia during a 6-year period at Asan Medical Center in comparison with severe pneumonia associated with MRSA.

Results

Between 2014 and 2019, there were 27 adult cases of severe C. striatum pneumonia. The majority of the cases (70.4%) were hospital-acquired pneumonia (HAP), and about half of the patients (51.9%) were immunocompromised. The incidence of C. striatum HAP significantly increased from 1.0% (2/200) in 2014-2015 to 5.4% (10/185) in 2018-2019 (P < 0.001), while the incidence of severe methicillin-resistant Staphylococcus aureus (MRSA) HAP significantly decreased from 12.0% to 2.7% during the same period. Of the 75 HAP cases whose bacterial pathogens were identified in 2018–2019, C. striatum was responsible for 13.3% of the cases. The 90-day mortality rates were similarly high in the C. striatum and MRSA groups (59.3% vs. 50.5%, P = 0.42).

Conclusion

In conclusion, C. striatum was a major pathogen of recent severe HAP and was associated with a substantially high mortality rate.

Disclosures

All Authors: No reported disclosures.

2192. Clinical and Molecular Characteristics of Severe Respiratory Syncytial Virus Pneumonia in Critically Ill Adults

Background

Respiratory syncytial virus (RSV) has been increasingly recognized as a frustrating cause of morbidity and mortality in adults. However, the clinical impact and molecular characteristics of severe RSV-associated pneumonia in critically ill adult patients have rarely been addressed.

Methods

This study, nested in a prospective cohort of severe pneumonia, was conducted at a 2,700-bed tertiary care hospital and comprised two parts. In part 1, the clinical characteristics of severe RSV-associated pneumonia were compared with severe influenza virus (IFV)-associated pneumonia between 2010 and 2019. In part 2, we performed phylogenetic and amino acid analyses of the G protein of RSV strains from three groups of different infection severity between 2015 and 2019 (Figure 1). Figure 1.Clinical samples for whole-genome sequencing in part 2.

Results

In part 1, 92 RSV- and 163 IFV-positive patients were identified. Structural lung diseases, diabetes mellitus, and malignancy were common underlying diseases in both groups. Immunocompromise (57.6% vs. 34.4%, p &lt; 0.001) and hospital acquisition (47.8% vs. 23.9%, p &lt; 0.001) were significantly more common in the RSV group. Clinical manifestations at diagnosis between the groups were generally similar. The mortalities of patients in both groups were similarly high (Table 1). In part 2, 26 RSV strains from three groups (group 1: 11 strains, group 2: 8 strains, and group 3: 7 strains) were analyzed. All isolated RSV-A and -B strains belonged to the ON1 and the BA9 genotypes, respectively. The phylogenetic analysis revealed that the adult severe pneumonia strains clustered by contemporary strains rather than other severe pneumonia strains. There were no significantly different genetic variations among the three groups, including the subtype clades, amino acid sequence substitutions, and changes in potential glycosylation sites. Table 1.Characteristic and outcomes of 255 patients with virus-associated severe pneumonia

Conclusion

Severe RSV pneumonia was more commonly associated with hospital acquisition and immunocompromised status. Overall clinical features and mortalities of the RSV group were comparable to the IFV group. The molecular characteristics of RSV strains from the adults with severe pneumonia were not distinct from strains from non-pneumonic adults or children, underscoring that the severity of RSV respiratory tract infection is mainly determined by host factors, not by viral factors.

Disclosures

All Authors: No reported disclosures.

Severe Pneumonia Caused by Corynebacterium striatum in Adults, Seoul, South Korea, 2014–2019

Most (70.4%) cases were hospital-acquired, and 51.9% of patients were immunocompromised.

We investigated the proportion and characteristics of severe Corynebacterium striatum pneumonia in South Korea during 2014–2019. As part of an ongoing observational study of severe pneumonia among adult patients, we identified 27 severe C. striatum pneumonia cases. Most (70.4%) cases were hospital-acquired, and 51.9% of patients were immunocompromised. C. striatum cases among patients with severe hospital-acquired pneumonia (HAP) increased from 1.0% (2/200) during 2014–2015 to 5.4% (10/185) during 2018–2019, but methicillin-resistant Staphylococcus aureus (MRSA) infections among severe HAP cases decreased from 12.0% to 2.7% during the same timeframe. During 2018–2019, C. striatum was responsible for 13.3% of severe HAP cases from which bacterial pathogens were identified. The 90-day mortality rates were similarly high in the C. striatum and MRSA groups. C. striatum was a major cause of severe HAP and had high mortality rates. This pathogen is emerging as a possible cause for severe pneumonia, especially among immunocompromised patients.

Neuromuscular blocking agents and opioids are major risk factors for developing pressure injuries in patients in the intensive care unit

BACKGROUND/AIMS

Patients in the intensive care unit (ICU) are at high risk for developing pressure injuries, which can cause severe complications and even increase the mortality risk. Therefore, prevention of pressure injuries is most important. In this study, we investigated the risk factors of pressure injury development in patients admitted to the ICU.

METHODS

We retrospectively analyzed patients ages &gt; 18 years admitted to the medical ICU in a tertiary hospital between January and December 2019. We collected patient baseline characteristics, medications received, mechanical ventilation or hemodialysis use, laboratory findings, and date of pressure injury onset and characteristics.

RESULTS

We analyzed 666 patients who did not have pressure injuries at ICU admission. Pressure injuries developed in 102 patients (15%). The risk of pressure injury development increased as the administration days for neuromuscular blocking agents (NMBAs; odds ratio [OR], 1.138; p = 0.019) and opioids (OR, 1.084; p = 0.028) increased, and if the patient had problem with friction and shear (OR, 2.203; p = 0.011).

CONCLUSION

The prolonged use of NMBAs and opioids can increase the risk of pressure injury development. Because these medications are associated with immobilization, using both should be minimized and patient early mobilization should be promoted. Among the Braden subscales, "friction and shear" was associated with the development of pressure injuries in ICU patients.

Continuous Piperacillin-Tazobactam Infusion Improves Clinical Outcomes in Critically Ill Patients with Sepsis: A Retrospective, Single-Centre Study

Continuous infusion of beta-lactam antibiotics has emerged as an alternative for the treatment of sepsis because of the favourable pharmacokinetics of continuous infusion. This study aimed to evaluate the survival benefits of continuous vs. intermittent infusion of piperacillin-tazobactam in critically ill patients with sepsis. We retrospectively conducted a single-centre study of continuous infusion vs. intermittent infusion of piperacillin-tazobactam for adult patients who met the Sepsis-3 criteria and were treated at a medical ICU within 48 h after hospitalisation between 1 May 2018 and 30 April 2020. The primary outcome was mortality at 28 days. A total of 157 patients (47 in the continuous group and 110 in the intermittent group) met the inclusion criteria for evaluation. The 28-day mortality rates were 12.8% in the continuous group and 27.3% in the intermittent group (p = 0.07). However, after adjustment for potential covariables, patients in the continuous group (12.8%) showed significantly lower mortality at 28 days than those in the intermittent group (27.3%; adjusted hazard ratio (HR), 0.31; 95% confidence interval (CI), 0.13-0.79; p = 0.013). In sepsis patients, continuous infusion of piperacillin-tazobactam may confer a benefit regarding the avoidance of mortality at 28 days compared with intermittent infusion.

Comprehensive analysis of immune responses in CLL patients after heterologous COVID-19 vaccination

Patients with chronic lymphocytic leukemia (CLL) treated with B-cell pathway inhibitors and anti-CD20 antibodies exhibit low humoral response rate (RR) following SARS-CoV-2 vaccination. To investigate the relationship between the initial transcriptional response to vaccination with ensuing B and T cell immune responses, we performed a comprehensive immune transcriptome analysis flanked by antibody and T cell assays in peripheral blood prospectively collected from 15 CLL/SLL patients vaccinated with heterologous BNT162b2/ChAdOx1 with follow up at a single institution. The two-dose antibody RR was 40% increasing to 53% after booster. Patients on BTKi, venetoclax ± anti-CD20 antibody within 12 months of vaccination responded less well than those under BTKi alone. The two-dose T cell RR was 80% increasing to 93% after booster. Transcriptome studies revealed that seven patients showed interferon-mediated signaling activation within 2 days and one at 7 days after vaccination. Increasing counts of COVID-19 specific IGHV genes correlated with B-cell reconstitution and improved humoral RR. T cell responses in CLL patients appeared after vaccination regardless of treatment status. A higher humoral RR was associated with BTKi treatment and B-cell reconstitution. Boosting was particularly effective when intrinsic immune status was improved by CLL-treatment.

Mortality of patients with hospital-onset sepsis in hospitals with all-day and non-all-day rapid response teams: a prospective nationwide multicenter cohort study

Background

Hospital-onset sepsis is associated with a higher in-hospital mortality rate than community-onset sepsis. Many hospitals have implemented rapid response teams (RRTs) for early detection and timely management of at-risk hospitalized patients. However, the effectiveness of an all-day RRT over a non-all-day RRT in reducing the risk of in-hospital mortality in patient with hospital-onset sepsis is unclear. We aimed to determine the effect of the RRT’s operating hours on in-hospital mortality in inpatient patients with sepsis.

Methods

We conducted a nationwide cohort study of adult patients with hospital-onset sepsis prospectively collected from the Korean Sepsis Alliance (KSA) Database from 16 tertiary referral or university-affiliated hospitals in South Korea between September of 2019 and February of 2020. RRT was implemented in 11 hospitals, of which 5 (45.5%) operated 24-h RRT (all-day RRT) and the remaining 6 (54.5%) had part-day RRT (non-all-day RRT). The primary outcome was in-hospital mortality between the two groups.

Results

Of the 405 patients with hospital-onset sepsis, 206 (50.9%) were admitted to hospitals operating all-day RRT, whereas 199 (49.1%) were hospitalized in hospitals with non-all-day RRT. A total of 73 of the 206 patients in the all-day group (35.4%) and 85 of the 199 patients in the non-all-day group (42.7%) died in the hospital (P = 0.133). After adjustments for co-variables, the implementation of all-day RRT was associated with a significant reduction in in-hospital mortality (adjusted odds ratio 0.57; 95% confidence interval 0.35–0.93; P = 0.024).

Conclusions

In comparison with non-all-day RRTs, the availability of all-day RRTs was associated with reduced in-hospital mortality among patients with hospital-onset sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04149-z.

Comparison of the Outcomes of Patients Starting Mechanical Ventilation in the General Ward Versus the Intensive Care Unit

OBJECTIVE

Mechanical ventilation is sometimes initiated in the general ward (GW) due to the shortage of intensive care unit (ICU) beds. We investigated whether invasive mechanical ventilation (MV) started in the GW affects the patient's prognosis compared with its initiation in the ICU.

METHODS

From January 2016 to December 2018, medical records of patients who started MV in the GW or ICU were collected. The 28-day mortality, ICU mortality, ventilator-free days, and complications related to the ventilator and the ventilator-free days were analyzed as outcomes.

RESULTS

A total of 673 patients were enrolled. Among these, 268 patients (39.8%) started MV in the GW and 405 patients (60.2%) started MV within 24 hours after admittance to the ICU. There was no difference in 28-day mortality between the 2 groups (27.2% versus 27.2%, P = 0.997). In addition, there was no difference between ventilator-related complication rates, ventilator-free days, or the length of hospital stay. A high Acute Physiology and Chronic Health Evaluation II score, the presence of solid tumor, the absence of chronic kidney diseases, and low platelet count were associated with higher 28-day mortality. However, the initiation of MV in the GW was not associated with an increase in 28-day mortality compared with the initiation in the ICU.

CONCLUSIONS

Starting MV in the GW was not a risk factor for 28-day mortality. Therefore, prompt application of a ventilator if medically indicated, regardless of the patient's location, is desirable if a skilled airway team and appropriate monitoring are available.

Characteristics and prognostic factors of very elderly patients admitted to the intensive care unit

Background

Korea is rapidly becoming a super aging society and is facing the increased burden of critical care for the elderly people. Traditionally, far-advanced age has been regarded as a triage criterion for intensive care unit (ICU) admission. We evaluated how the characteristics and prognostic factors of very elderly patients (≥85 years) admitted to the ICU changed over the last decade.

Methods

We retrospectively evaluated the data of patients admitted to the ICU over 11 years (2007–2017). The clinical characteristics and outcomes of the very elderly-patients group were evaluated. Factors associated with mortality were assessed by a cox regression analysis.

Results

Comparing the first half (2007–2012) and the second half (2013–2017) of the study period, the proportion of very elderly group increased from 603/47,657 (1.3%), to 697/37,756 (1.8%) (P<0.001). Among 1,294 very elderly patients, 1,274 patients were analyzed excluding hopeless discharge (n=20). The non-surgical reasons for ICU admission (67.0% vs. 76.1%, P<0.001) and the percentage of patients with co-morbidities (78.3% vs. 82.7%, P=0.048) were increased. Nevertheless, the hospital mortality decreased (21.3% vs. 14.9%, P=0.001). High creatinine levels, use of vasopressors and ventilator weaning failure were associated with in-hospital mortality.

Conclusions

The proportion of very elderly people in the ICU increased over the last decade. The non-surgical causes of ICU admission increased compared with the surgical causes. Despite an increasement in ICU admissions of very elderly patients, in-hospital mortality of very elderly ICU patients decreased.

Reliability of Central Venous Blood Gas Values Compared With Arterial Blood Gas Values in Critically Ill Patients

BACKGROUND

Central venous blood gas (cVBG) values are correlated with arterial blood gas (ABG) values. However, the substitution of cVBG values for ABG values in critically ill patients remains uninvestigated. Thus, we investigated the reliability between cVBG and ABG values and sought to define the conditions that could improve the reliability of cVBG values as a substitute.

METHODS

We conducted a prospective comparison of 292 sets of cVBG values and ABG values from 82 subjects admitted to the medical ICU between October 2017-July 2018. Paired cVBG and ABG samples were collected daily during the first 5 d of ICU treatment and on days 8, 15, 22, and 29. Intraclass correlation coefficient (ICC) and Bland-Altman limits of agreement (LOA) were obtained.

RESULTS

The ICC between ABG and cVBG was 0.626 for pH, 0.696 for P_CO2 , 0.869 for bicarbonate, 0.866 for base excess, and 0.989 for lactic acid. Bland-Altman plots showed clinically unacceptable LOA between all parameters. Subgroup analysis indicated a significant increase in the ICCs of P_CO2 in samples with mechanical ventilation (0.0574-0.735, P = .02) and central venous oxygen saturation (ScvO₂) ≥ 70% (0.611-0.763, P = .008). After adjustment, the 95% LOA between ABG and cVBG was -0.06 to 0.07 for pH and -7.09 to 7.05 for P_CO2 in mechanically ventilated subjects with ScvO₂ ≥ 70%.

CONCLUSIONS

ABG and cVBG values showed clinically acceptable agreements and improved reliability in mechanically ventilated subjects with ScvO₂ ≥ 70%. cVBG analysis may be a substitute for ABG analysis in mechanically ventilated patients once tissue perfusion is restored.

Prognostic implication of bronchoalveolar lavage fluid analysis in patients with Pneumocystis jirovecii pneumonia without human immunodeficiency virus infection

Background

The prognostic value of bronchoalveolar lavage (BAL) fluid analysis in non-human immunodeficiency virus (HIV)-infected patients with Pneumocystis jirovecii pneumonia (PJP) has not been well elucidated. We aimed to investigate the prognostic implication of BAL fluid analysis in non-HIV patients with PJP.

Methods

The data of 178 non-HIV patients diagnosed with PJP based on the results of the polymerase chain reaction assay of BAL fluid specimens between April 2018 and December 2020 were retrospectively reviewed. The clinical characteristics, laboratory findings, and BAL fluid analysis results of patients who died within 90 days after hospital admission were compared.

Results

Twenty patients (11.2%) died within 90 days from admission. The neutrophil count in BAL fluid was significantly higher (median 22.0%, interquartile range [IQR] 2.0–46.0% vs. median 6.0%, IQR 2.0–18.0%, P = 0.044), while the lymphocyte count was significantly lower (median 24.0%, IQR 7.0–37.0% vs. median 41.0%, IQR 22.5–60.5%, P = 0.001) in the non-survivor group compared with that in the survivor group. In the multivariate analysis, the C-reactive protein level (odds ratio [OR] 1.093, 95% confidence interval [CI] 1.020–1.170, P = 0.011) and a BAL fluid lymphocyte count of ≤ 30% (OR 3.353, 95% CI 1.101–10.216, P = 0.033) were independently associated with mortality after adjusting for albumin and lactate dehydrogenase levels.

Conclusion

A low lymphocyte count in BAL fluid may be a predictor of mortality in non-HIV patients with PJP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02041-8.

Heterologous ChAdOx1-BNT162b2 vaccination in Korean cohort induces robust immune and antibody responses that includes Omicron

Heterologous ChAdOx1-BNT162b2 vaccination induces a stronger immune response than BNT162b2-BNT162b2. Here, we investigated the molecular transcriptome, germline allelic variants of immunoglobulin loci, and anti-Omicron antibody levels in 46 office and lab workers from the Republic of Korea following ChAdOx1-BNT162b2 vaccination. Anti-spike-specific IgG antibody levels against the ancestral SARS-CoV-2 strain increased from 70 AU/ml to 14,000 AU/ml to 142,000 AU/ml one, three and seven days following the second vaccination. Titers against VOC, including Omicron, were two-fold to three-fold lower, yet higher than those measured following BNT162b2-BNT162b2 vaccination. RNA-seq of peripheral immune cells demonstrated activation of interferon pathways with increased IGHV clonal transcripts encoding neutralizing antibodies. scRNA-seq revealed enriched B cell and CD4⁺ T cell responses in both ChAdOx1-BNT162b2 and BNT162b2-BNT162b2 recipients, but a stronger clonal expansion of memory B cells with ChAdOx1-BNT162b2. In summary, heterologous ChAdOx1-BNT162b2 provides an innate and adaptive immune response that exceeds homologous BNT162b2 vaccination.

Near-infrared spectroscopy during cardiopulmonary resuscitation for pediatric cardiac arrest: a prospective, observational study

AIM

Cerebral oxygenation (rSO2) is not routinely measured during pediatric cardiopulmonary resuscitation (CPR). We aimed to determine whether higher intra-arrest rSO2 was associated with return of spontaneous circulation (ROSC) and survival to hospital discharge.

METHODS

Prospective, single-center observational study of cerebral oximetry using near-infrared spectroscopy (NIRS) during pediatric cardiac arrest from 2016 to 2020. Eligible patients had ≥30 s of rSO2 data recorded during CPR. We compared median rSO2 and percentage of rSO2 measurements above a priori thresholds for the entire event and the final five minutes of the CPR event between patients with and without ROSC and survival to discharge.

RESULTS

Twenty-one patients with 23 CPR events were analyzed. ROSC was achieved in 17/23 (73.9%) events and five/21 (23.8%) patients survived to discharge. The median rSO2 was higher for events with ROSC vs. no ROSC for the overall event (62% [56%, 70%] vs. 45% [35%, 51%], p = 0.025) and for the final 5 minutes of the event (66% [55%, 72%] vs. 43% [35%, 44%], p = 0.01). Patients with ROSC had a higher percentage of measurements above 50% during the final five minutes of CPR (100% [100%, 100%] vs. 0% [0%, 29%], p = 0.01). There was no association between rSO2 and survival to discharge.

CONCLUSIONS

Higher cerebral rSO2 during CPR for pediatric cardiac arrest was associated with higher rates of ROSC but not with survival to discharge.

Outcomes of critically ill patients according to the perception of intensivists on the appropriateness of intensive care unit admission

Background

It is important for intensivists to determine which patient may benefit from intensive care unit (ICU) admission. We aimed to assess the outcomes of patients perceived as non-beneficially or beneficially admitted to the ICU and evaluate whether their prognosis was consistent with the intensivists’ perception.

Methods

A prospective observational study was conducted on patients admitted to the medical ICU of a tertiary referral center between February and April 2014. The perceptions of four intensivists at admission (day 1) and on day 3 were investigated as non-beneficial admission, beneficial admission, or indeterminate state.

Results

A total of 210 patients were enrolled. On days 1 and 3, 22 (10%) and 23 (11%) patients were judged as having non-beneficial admission; 166 (79%) and 159 (79%), beneficial admission; and 22 (10%) and 21 (10%), indeterminate state, respectively. The ICU mortality rates of each group on day 1 were 59%, 23%, and 59%, respectively; their 6-month mortality rates were 100%, 48%, and 82%, respectively. The perceptions of non-beneficial admission or indeterminate state were the significant predictors of ICU mortality (day 3; odds ratio [OR], 4.049; 95% confidence interval [CI], 1.892–8.664; P<0.001) and 6-month mortality (day 1: OR, 4.983; 95% CI, 1.260–19.703; P=0.022; day 3: OR, 4.459; 95% CI, 1.162–17.121; P=0.029).

Conclusions

The outcomes of patients perceived as having non-beneficial admission were extremely poor. The intensivists’ perception was important in predicting patients’ outcomes and was more consistent with long-term prognosis than with immediate outcomes. The intensivists’ role can be reflected in limited ICU resource utilization.

Rapid Response System Improves Sepsis Bundle Compliances and Survival in Hospital Wards for 10 Years

BACKGROUND

Hospitalized patients can develop septic shock at any time. Therefore, it is important to identify septic patients in hospital wards and rapidly perform the optimal treatment. Although the sepsis bundle has already been reported to improve survival rates, the controversy over evidence of the effect of in-hospital sepsis continues to exist. We aimed to estimate the outcomes and bundle compliance of patients with septic shock in hospital wards managed through the rapid response system (RRS).

METHODS

A retrospective cohort study of 976 patients with septic shock managed through the RRS at an academic, tertiary care hospital in Korea from 2008 to 2017.

RESULTS

Of the 976 enrolled patients, the compliance of each sepsis bundle was high (80.8-100.0%), but the overall success rate of the bundle was low (58.3%). The compliance rate for achieving the overall sepsis bundle increased from 26.5% to 70.0%, and the 28-day mortality continuously decreased from 50% to 32.1% over 10 years. We analyzed the two groups according to whether they completed the overall sepsis bundle or not. Of the 976 enrolled patients, 569 (58.3%) sepsis bundles were completed, whereas 407 (41.7%) were incomplete. The complete bundle group showed lower 28-day mortality than the incomplete bundle group (37.1% vs. 53.6%, p < 0.001). In the multivariate multiple logistic regression model, the 28-day mortality was significantly associated with the complete bundle (adjusted odds ratio (OR), 0.61; 95% confidence intervals (CI), 0.40-0.91; p = 0.017). The obtaining of blood cultures (adjusted OR, 0.45; 95% CI, 0.33-0.63; p < 0.001) and lactate re-measurement (adjusted OR, 0.69; 95% CI, 0.50-0.95; p = 0.024) in each component of the sepsis bundle were associated with the 28-day mortality.

CONCLUSIONS

The rapid response system provides improving sepsis bundle compliances and survival in patients with septic shock in hospital wards.

Long-Term Outcomes After In-Hospital Cardiac Arrest: Does Pre-arrest Skeletal Muscle Depletion Matter?

Background: Skeletal muscle depletion is prevalent in elderly patients and is associated with unfavorable outcomes in patients with chronic diseases. However, the relationship between skeletal muscle mass and neurological outcomes following in-hospital cardiac arrest (IHCA) has not been evaluated. The aim of this study was to investigate whether skeletal muscle status before cardiac arrest is an independent factor affecting neurological outcomes in patients with IHCA. Methods: We reviewed a prospectively enrolled registry of IHCA patients. Consecutive adult patients (>18 years) admitted to a tertiary care hospital from 2013 to 2019 were included in the study. Of these, 421 patients who underwent abdominopelvic computed tomography within 3 months of cardiac arrest were included. Skeletal muscle index (SMI) was measured at the third lumbar vertebra, and skeletal muscle depletion was defined using sex- and body mass index-specific cutoffs of SMI. The primary outcome was a Cerebral Performance Category score of 1 or 2 at 6 months after cardiac arrest, which was considered a good neurological outcome. Results: Of the 421 patients, 248 (58.9%) had skeletal muscle depletion before IHCA. The patients without skeletal muscle depletion showed significantly better neurological outcomes at 6 months after cardiac arrest than those with pre-arrest muscle depletion (20.8 vs. 10.9%, p = 0.004). The absence of skeletal muscle depletion was significantly associated with good neurological outcomes in a multivariable logistic analysis (OR = 3.49, 95% confidence intervals: 1.83-6.65, p < 0.001), along with the absence of diabetes, presence of active cancer, shockable rhythm, and short resuscitation duration. Conclusion: Pre-arrest skeletal muscle depletion was associated with long-term mortality and poor neurological outcomes after IHCA. Skeletal muscle depletion may be used as a tool to identify at-risk patients who may benefit from aggressive treatments.

Effects of high-flow nasal cannula in patients with mild to moderate hypercapnia: a prospective observational study

Background

Evidence for using high-flow nasal cannula (HFNC) in hypercapnia is still limited. Most of the clinical studies had been conducted retrospectively, and there had been conflicting reports for the effects of HFNC on hypercapnia correction in prospective studies. Therefore, more evidence is needed to understand the effect of the HFNC in hypercapnia.

Methods

We conducted a multicenter prospective observational study after applying HFNC to 45 hospitalized subjects who had moderate hypercapnia (arterial partial pressure of carbon dioxide [PaCO₂], 43–70 mm Hg) without severe respiratory acidosis (pH <7.30). The primary outcome was a change in PaCO₂ level in the first 24 hours of HFNC use. The secondary outcomes were changes in other parameters of arterial blood gas analysis, changes in respiration rates, and clinical outcomes.

Results

There was a significant decrease in PaCO₂ in the first hour of HFNC application (-3.80 mm Hg; 95% confidence interval, -6.35 to -1.24; P<0.001). Reduction of PaCO₂ was more prominent in subjects who did not have underlying obstructive lung disease. There was a correction in pH, but no significant changes in respiratory rate, bicarbonate, and arterial partial pressure of oxygen/fraction of inspired oxygen ratio. Mechanical ventilation was not required for 93.3% (42/45) of our study population.

Conclusions

We suggest that HFNC could be a safe alternative for oxygen delivery in hypercapnia patients who do not need immediate mechanical ventilation. With HFNC oxygenation, correction of hypercapnia could be expected, especially in patients who do not have obstructive lung diseases.

Dynamic inhomogeneity of aeration along the vertical axis of the lung may predict weaning failure regardless of diaphragm dysfunction

PURPOSE

This study aimed to investigate dynamic changes of lung aeration during a spontaneous breathing trial (SBT) in patients with diaphragm dysfunction (DD) and to predict weaning failure using electrical impedance tomography (EIT).

MATERIALS AND METHODS

We enrolled 40 adult patients who received mechanical ventilation over 48 h and were eligible for SBT with a T-piece. All patients were screened for DD using ultrasonography before SBT. EIT data, including global inhomogeneity index (an off-site parameter), and temporal skew of aeration (TSA) (an on-site parameter) were collected.

RESULTS

Sixteen (40%) patients had DD. During SBT, the tidal impedance variation decreased by 32% from baseline in patients with DD and by 14% in those without DD (p = 0.001). The global inhomogeneity index in the SBT failure group (n = 9) was 0.92 (median), and that of the SBT success group was 0.65 (p = 0.004). The TSA along the vertical axis of the lung was 12.0% and 2.0%, respectively (p = 0.001). With a vertical TSA cutoff of ≥4.35%, SBT failure was predicted with a sensitivity of 88.9% and specificity of 96.9% (area under the curve: 0.955).

CONCLUSION

Dynamic inhomogeneity of aeration along the vertical axis of the lung as assessed using TSA predicts SBT failure regardless of DD.

TRIAL REGISTRATION

This trial was retrospectively registered at cris.nih.go.kr (identifier: KCT003567; release date February 27, 2019).

Severe Human Bocavirus-Associated Pneumonia in Adults at a Referral Hospital, Seoul, South Korea

We report a case series of severe human bocavirus–associated pneumonia in adults in Seoul, South Korea. The virus accounted for 0.5% of all severe pneumonia cases. Structural lung disease and hematologic malignancy were common underlying diseases. Overall death rate was 54.5%. Higher death rates were associated with co-infection (83.3%) and immunocompromise (80.0%).

Factors and Outcomes of Intensive Care Unit Readmission in Elderly Patients

INTRODUCTION

An increase in age has been observed among patients admitted to the intensive care unit (ICU). Age is a well-known risk factor for ICU readmission and mortality. However, clinical characteristics and risk factors of ICU readmission of elderly patients (≥65 years) have not been studied.

METHODS

This retrospective single-center cohort study was conducted in a total of 122-bed ICU of a tertiary care hospital in Seoul, Korea. A total of 85,413 patients were enrolled in this hospital between January 1, 2007, and December 31, 2017. The odds ratio of readmission and in-hospital mortality was calculated by logistic regression analysis.

RESULTS

Totally, 29,503 patients were included in the study group, of which 2,711 (9.2%) had ICU readmissions. Of the 2,711 readmitted patients, 472 patients were readmitted more than once (readmitted 2 or more times to the ICU, 17.4%). In the readmitted patient group, there were more males, higher sequential organ failure assessment (SOFA) scores, and hospitalized for medical reasons. Length of stay (LOS) in ICU and in-hospital were longer, and 28-day and in-hospital mortality was higher in readmitted patients than in nonreadmitted patients. Risk factors of ICU readmission included the ICU admission due to medical reason, SOFA score, presence of chronic heart disease, diabetes mellitus, chronic kidney disease, transplantation, use of mechanical ventilation, and initial ICU LOS. ICU readmission and age (over 85 years) were independent predictors of in-hospital mortality on multivariable analysis. The delayed ICU readmission group (>72 h) had higher in-hospital mortality than the early readmission group (≤72 h) (20.6 vs. 16.2%, p = 0.005).

CONCLUSIONS

ICU readmissions occurred in 9.2% of elderly patients and were associated with poor prognosis and higher mortality.

Predictive value of pre-arrest albumin level with GO-FAR score in patients with in-hospital cardiac arrest

We investigated whether combining the pre-arrest serum albumin level could improve the performance of the Good Outcome Following Attempted Resuscitation (GO-FAR) score for predicting neurologic outcomes in in-hospital cardiac arrest patients. Adult patients who were admitted to a tertiary care hospital between 2013 and 2017 were assessed. Their pre-arrest serum albumin levels were measured within 24 h before the cardiac arrest. According to albumin levels, the patients were divided into quartiles and were assigned 1, 0, 0, and, - 2 points. Patients were allocated to the derivation (n = 419) and validation (n = 444) cohorts. The proportion of favorable outcome increased in a stepwise manner across increasing quartiles (p for trend < 0.018). Area under receiver operating characteristic curve (AUROC) of the albumin-added model was significantly higher than that of the original GO-FAR model (0.848 vs. 0.839; p = 0.033). The results were consistent in the validation cohort (AUROC 0.799 vs. 0.791; p = 0.034). Net reclassification indices of the albumin-added model were 0.059 (95% confidence interval [CI] - 0.037 to 0.094) and 0.072 (95% CI 0.013-0.132) in the derivation and validation cohorts, respectively. An improvement in predictive performance was found by adding the ordinal scale of pre-arrest albumin levels to the original GO-FAR score.

Effect of corticosteroid therapy in the early phase of acute respiratory distress syndrome: a propensity-matched cohort study

BACKGROUND/AIMS

It is unclear whether corticosteroid use in patients with acute respiratory distress syndrome (ARDS) improves survival. This study aimed to investigate whether the administration of corticosteroids to patients in the early phase of moderate to severe ARDS is associated with improved outcomes.

METHODS

We analyzed the data of patients who received corticosteroids within 7 days of the onset of ARDS between June 2006 and December 2015 at a single tertiary teaching hospital. A total of 565 patients admitted with moderate to severe ARDS were eligible. The outcomes of patients treated with methylprednisolone 40 to 180 mg/day or equivalent (n = 404) were compared to those who did not receive steroids (n = 161). The primary and secondary outcomes were 28- and 90-day mortality rates, respectively. Propensity scores were used to adjust for baseline covariates.

RESULTS

The overall mortality at 28 days was not significantly different between the corticosteroid-treated and control groups (43.8% vs. 41%, p = 0.541). At 90 days, the overall mortality rate was higher in the corticosteroid-treated group than in the control group (59.2% vs. 48.4%, p = 0.021). However, on propensity score matching, corticosteroid therapy was not associated with a higher 28-day mortality rate (odds ratio, 1.031; 95% confidence interval, 0.657 to 1.618; p = 0.895) and 90 days (odds ratio, 1.435; 95% confidence interval, 0.877 to 2.348; p = 0.151).

CONCLUSION

Corticosteroid therapy was not associated with 28- or 90-day mortality in the early phase of moderate to severe ARDS on propensity score matching analysis.

Derivation and validation of modified early warning score plus SpO2/FiO2 score for predicting acute deterioration of patients with hematological malignancies

BACKGROUND/AIMS

Scoring systems play an important role in predicting intensive care unit (ICU) admission or estimating the risk of death in critically ill patients with hematological malignancies. We evaluated the modified early warning score (MEWS) for predicting ICU admissions and in-hospital mortality among at-risk patients with hematological malignancies and developed an optimized MEWS.

METHODS

We retrospectively analyzed derivation cohort patients with hematological malignancies who were managed by a medical emergency team (MET) in the general ward and prospectively validated the data. We compared the traditional MEWS with the MEWS plus SpO2/FiO2 (MEWS_SF) score, which were calculated at the time of MET contact.

RESULTS

In the derivation cohort, the areas under the receiver-operating characteristic (AUROC) curves were 0.81 for the MEWS (95% confidence interval [CI], 0.76 to 0.87) and 0.87 for the MEWS_SF score (95% CI, 0.87 to 0.92) for predicting ICU admission. The AUROC curves were 0.70 for the MEWS (95% CI, 0.63 to 0.77) and 0.76 for the MEWS_SF score (95% CI, 0.70 to 0.83) for predicting in-hospital mortality. In the validation cohort, the AUROC curves were 0.71 for the MEWS (95% CI, 0.66 to 0.77) and 0.83 for the MEWS_SF score (95% CI, 0.78 to 0.87) for predicting ICU admission. The AUROC curves were 0.64 for the MEWS (95% CI, 0.57 to 0.70) and 0.74 for the MEWS_SF score (95% CI, 0.69 to 0.80) for predicting in-hospital mortality.

CONCLUSION

Compared to the traditional MEWS, the MEWS_SF score may be a useful tool that can be used in the general ward to identify deteriorating patients with hematological malignancies.

The quick sepsis-related organ failure score has limited value for predicting adverse outcomes in sepsis patients with liver cirrhosis

BACKGROUND/AIMS

The quick Sepsis-related Organ Failure Assessment (qSOFA) is a newly developed risk stratification tool, which has been presented along with a new sepsis definition, to classify infected patients outside of the intensive care unit (ICU). We evaluated the clinical usefulness of qSOFA for predicting adverse outcomes in sepsis patients with liver cirrhosis.

METHODS

We performed a retrospective cohort study to assess the utility of qSOFA in sepsis patients with liver cirrhosis for whom medical emergency teams (METs) were activated in general wards at an academic tertiary care hospital between March 2008 and December 2015. qSOFA, Systemic inflammatory response syndrome (SIRS), modified early warning score (MEWS), and sequential (sepsis-related) organ failure assessment (SOFA) scores were calculated according to data at MET activation.

RESULTS

Of 188 patients, 69 (36.7%) had a qSOFA score of 0 or 1 point and 119 (63.3%) had ≥ 2 points. The areas under the receiver operating characteristic curve (AUROC) for ICU transfer on the SOFA (AUROC, 0.691; 95% confidence interval [CI], 0.615 to 0.767) or MEWS (AUROC, 0.663; 95% CI, 0.586 to 0.739) were significantly higher compared to those for qSOFA (AUROC, 0.589; 95% CI, 0.507 to 0.671) or SIRS (AUROC, 0.533; 95% CI, 0.451 to 0.616).

CONCLUSION

Our findings suggest that qSOFA score may have limited utility in predicting adverse outcomes in sepsis patients with liver cirrhosis at MET activation. Either MEWS or another screening tool is needed for detecting early sepsis in these patients.

Predictive powers of the Modified Early Warning Score and the National Early Warning Score in general ward patients who activated the medical emergency team

Background

The current early warning scores may be insufficient for medical emergency teams (METs) to use in assessing the severity and the prognosis of activated patients. We evaluated the predictive powers of the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS) for 28-day mortality and to analyze predictors of 28-day mortality in general ward patients who activate the MET.

Methods

Adult general ward inpatients who activated the MET in a tertiary referral teaching hospital between March 2009 and December 2016 were included. The demographic and clinical characteristics and physiologic parameters at the time of MET activation were collected, and MEWS and NEWS were calculated.

Results

A total of 6,729 MET activation events were analyzed. Patients who died within 28 days were younger (mean age 60 vs 62 years), were more likely to have malignancy (72% vs 53%), were more likely to be admitted to the medical department rather than the surgical department (93% vs 80%), had longer intervals from admission to MET activation (median, 7 vs 5 days), and were less likely to activate the MET during nighttime hours (5 PM to 8 AM) (61% vs 66%) compared with those who did not die within 28 days (P < 0.001 for all comparisons). The areas under the receiver operating characteristic curves of MEWS and NEWS for 28-day mortality were 0.58 (95% CI, 0.56–0.59) and 0.60 (95% CI, 0.59–0.62), which were inferior to that of the logistics regression model (0.73; 95% CI, 0.72–0.74; P < 0.001 for both comparisons).

Conclusions

Both the MEWS and NEWS had poor predictive powers for 28-day mortality in patients who activated the MET. A new scoring system is needed to stratify the severity and prognosis of patients who activated the MET.

Iatrogenic Opioid Withdrawal Syndrome in Critically Ill Patients: a Retrospective Cohort Study

BACKGROUND

Opioid withdrawal syndrome (OWS) may occur following the reduction or discontinuation of opioid analgesics. In critically ill pediatric patients, OWS is a common and clinically significant condition. However, OWS in adult patients has not been assessed in detail. Therefore, we aimed to investigate the incidence, risk factors, and clinical features of OWS in mechanically ventilated patients treated in an adult intensive care unit (ICU).

METHODS

This study was a retrospective evaluation of data from patients treated in the medical ICU for > 3 days and who received only one type of opioid analgesic. OWS was assessed over a 24 hours period from discontinuation or reduction (by > 50%) of continuous opioid infusion. OWS was defined as the presence of ≥ 3 central nervous system or autonomic nervous system symptoms.

RESULTS

In 126 patients treated with remifentanil (n = 58), fentanyl (n = 47), or morphine (n = 21), OWS was seen in 31.0%, 36.2%, and 9.5% of patients, respectively (P = 0.078). The most common symptom was a change in respiratory rate (remifentanil, 94.4%; fentanyl, 76.5%; morphine, 100%). Multivariate Cox-proportional hazards model showed that OWS was negatively associated with morphine treatment (hazard ratio [HR], 0.17; 95% confidence interval [CI], 0.037-0.743) and duration of opioid infusion (HR, 0.566; 95% CI, 0.451-0.712).

CONCLUSION

OWS is not uncommon in mechanically ventilated adult patients who received continuous infusion of opioids for > 3 days. The use of morphine may be associated with a decreased risk of OWS.

Development of a Real-Time Risk Prediction Model for In-Hospital Cardiac Arrest in Critically Ill Patients Using Deep Learning: Retrospective Study

BACKGROUND

Cardiac arrest is the most serious death-related event in intensive care units (ICUs), but it is not easily predicted because of the complex and time-dependent data characteristics of intensive care patients. Given the complexity and time dependence of ICU data, deep learning-based methods are expected to provide a good foundation for developing risk prediction models based on large clinical records.

OBJECTIVE

This study aimed to implement a deep learning model that estimates the distribution of cardiac arrest risk probability over time based on clinical data and assesses its potential.

METHODS

A retrospective study of 759 ICU patients was conducted between January 2013 and July 2015. A character-level gated recurrent unit with a Weibull distribution algorithm was used to develop a real-time prediction model. Fivefold cross-validation testing (training set: 80% and validation set: 20%) determined the consistency of model accuracy. The time-dependent area under the curve (TAUC) was analyzed based on the aggregation of 5 validation sets.

RESULTS

The TAUCs of the implemented model were 0.963, 0.942, 0.917, 0.875, 0.850, 0.842, and 0.761 before cardiac arrest at 1, 8, 16, 24, 32, 40, and 48 hours, respectively. The sensitivity was between 0.846 and 0.909, and specificity was between 0.923 and 0.946. The distribution of risk between the cardiac arrest group and the non-cardiac arrest group was generally different, and the difference rapidly increased as the time left until cardiac arrest reduced.

CONCLUSIONS

A deep learning model for forecasting cardiac arrest was implemented and tested by considering the cumulative and fluctuating effects of time-dependent clinical data gathered from a large medical center. This real-time prediction model is expected to improve patient's care by allowing early intervention in patients at high risk of unexpected cardiac arrests.

Validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) score in an East Asian population

AIM

The Good Outcome Following Attempted Resuscitation (GO-FAR) score is useful for identifying patients post-arrest with very poor neurologic outcomes and may thus be utilized when counseling family members on do-not-attempt-resuscitation (DNAR) order. We validated the GO-FAR score for neurologically intact survival in patients with in-hospital cardiac arrest (IHCA) in an East Asian country in which DNAR order not common.

METHODS

Retrospective study about patients who experienced IHCA from 2013 to 2017 with a primary outcome of neurologically intact survival, defined as a CPC score 1 or 2 at discharge. GO-FAR score categorizes the patients into 4 groups: a very low (<1%), low (1%-3%), average (>3%-15%), or higher than average (>15%) likelihood of neurologically intact survival.

RESULTS

Of the 1011 included patients, the rates of survival discharge and neurologically intact survival at discharge were 25.4% and 16.0%, respectively. The area under the receiver operating characteristics curve of GO-FAR score for good neurological outcome was 0.81 (95% CI, 0.78-0.84). Patients with low or very low probability of survival had a likelihood of 0.9% (95% CI, 0.0-2.0), but for those under 40 years old, it was increased to 4.2% (95% CI, 0.0-12.2). Patients with average or above-average probabilities had likelihoods of of 18.5% (95% CI, 15.3-21.6) and 50.5% (95% CI, 40.6-60.5), respectively.

CONCLUSIONS

The GO-FAR score well-predicted the neurologically intact survival of East Asian patients with IHCA. This tool may be used as part of a shared decision regarding DNAR orders.

High-flow nasal cannula oxygen therapy in idiopathic pulmonary fibrosis patients with respiratory failure

Background

High-flow nasal cannula (HFNC) oxygen therapy is widely applied in idiopathic pulmonary fibrosis (IPF) patients with acute respiratory failure (ARF); however, its advantages over mechanical ventilation (MV) remain unclear. We aimed to compare the clinical outcomes of HFNC oxygen therapy and MV in IPF patients with respiratory failure.

Methods

A retrospective descriptive study of patients with IPF admitted between January 2015 and December 2017 who underwent HFNC oxygen therapy or MV during hospitalization was conducted. The primary outcome was the comparison of in-hospital mortality among HFNC only group, MV with prior HFNC group, and MV only group.

Results

A total of 61 patients with IPF and ARF were included in the current study. Forty-five patients received HFNC oxygen therapy without endotracheal intubation and 16 received MV. The overall hospital mortality rate was 59.0%, of which 53.3% was for HFNC oxygen therapy and 55.6% (5/9) for MV only group (P=1.000). Although no significant difference in the mortality rate was observed among three groups, that of MV with prior HFNC oxygen therapy (n=7) was 100% (P=0.064). Additionally, the HFNC oxygen therapy group showed shorter length of hospital and ICU stay than the MV group (P<0.001).

Conclusions

Patients with IPF and ARF who received MV with prior HFNC oxygen therapy showed increased mortality rate than those who received HFNC only oxygen therapy or MV. Considering the complication rate of MV, need for lung transplantation, and the will to undergo end-of-life care, a proper transition from HFNC oxygen therapy to MV should be planned cautiously.

The effect of human adipose-derived stem cells on lipopolysaccharide-induced acute respiratory distress syndrome in mice

Background

Acute respiratory distress syndrome (ARDS) is a type of acute respiratory failure in critically ill patients. Recently, several treatment modalities have been proposed for ARDS, but it still has a high mortality rate. In general, the role of mesenchymal stem cells (MSCs) in controlling inflammatory responses has been studied in various immune-associated diseases in humans and animals. However, only a few studies reported adipose-derived stem cells (ASCs), which are easier to isolate, are currently emerging as an attractive treatment option in ARDS. Therefore, in this study, we investigated the therapeutic effects of human ASCs and the regulation of inflammatory responses in an ARDS mouse model.

Methods

In the ARDS model, lipopolysaccharide (LPS) (5 mg/kg) was administered via the intra tracheal injection method. The mice were divided into the following four groups: (I) saline + medium; (II) saline + ASCs (2×10⁵); (III) LPS + medium; (IV) LPS + ASCs. The ARDS observation time was divided into short and long term. LPS administration increased the concentration of proinflammatory cytokines, which was a consistent systemic inflammatory response.

Results

LPS/ASC group showed less neutrophil infiltration and less alveolar hemorrhage or congestion than did the LPS group. The lung injury scores of the LPS/ASC group were lower than those of the LPS group (3.8±0.9 vs. 6.8±1.1; P=0.03) at day 2. Compared to the LPS group, LPS/ASC group showed reduced collagen deposition around the vessels and fibrosis accompanied by alveolar septal or interstitial thickening and lower MPO levels than did the LPS group (453.2±26.2 vs. 670.2±65.9 pg/mL; P<0.01) at day 7.

Conclusions

ASC therapy can inhibit neutrophil recruitment, which shows trend of reducing short term lung injury (day 2) and affecting fibrosis in long term (day 7). Further studies are warranted to understand the mechanism and improve the therapeutic effect of ASCs.

Impact of Body Composition Status on 90-Day Mortality in Cancer Patients with Septic Shock: Sex Differences in the Skeletal Muscle Index

Abnormalities in body composition are associated with poor prognosis in cancer patients. We investigated the association between body composition and 90-day mortality in cancer patients who developed septic shock. We included consecutive septic shock patients with active cancer from 2010 to 2017. The muscle area at the level of the third lumbar vertebra was measured by computed tomography upon emergency department admission and adjusted by height squared, yielding the Skeletal Muscle Index (SMI). Hazard ratios (HRs) and 95% confidence intervals (CIs) for 90-day mortality were estimated using a Cox proportional hazards model. Among 478 patients, the prevalence of muscle depletion was 87.7%. Among markers of body composition, the SMI only differed significantly between non-survivors and survivors (mean, 35.48 vs. 33.32 cm²/m²; P = 0.002) and was independently associated with lower 90-day mortality (adjusted HR, 0.970; P = 0.001). The multivariable-adjusted HRs (95% CI) for 90-day mortality comparing quartiles 2, 3, and 4 of the SMI to the lowest quartile were 0.646 (0.916–1.307), 0.620 (0.424–0.909), and 0.529 (0.355–0.788), respectively. The associations were evident in male patients, but not in female patients. The SMI was independently associated with 90-day mortality in cancer patients with septic shock. The graded association between the SMI and 90-day mortality was observed in male patients.

Risk factors of severe hemoptysis in patients with fungus ball

Background

Hemoptysis is one of the most important complications associated with fungus ball. However, the association of the primary size of the fungus ball and its change with the incidence of hemoptysis was not fully established. This study aims to determine the clinical risk factors of severe hemoptysis and natural course of fungus ball.

Methods

A retrospective study on patients with fungus ball was performed. Patients with severe hemoptysis-related events were compared to those without events, and the predictors for severe hemoptysis were investigated by Cox regression analysis. Three subgroups (decreased, stable, and increased) were classified according to the long-term size change, and the severe hemoptysis-free survival duration was analyzed by the Kaplan-Meier survival curve.

Results

Among 173 patients, 50 (28.9%) experienced severe hemoptysis-related events. Risk-adjusted analysis revealed that age [hazard ratio (HR), 0.964; 95% confidence interval (CI), 0.939-0.989], blood-tinged sputum [HR, 2.717; 95% CI, 1.513-4.879], and thick wall cavitary fungus balls [HR, 2.332; 95% CI, 1.290-4.215] were significant predictors of severe hemoptysis-related events in patients with fungus ball. However, the baseline size of the fungus ball and its change rate were not independent risk factors for severe hemoptysis-related events. Besides, the decreased group did not have a favorable outcome in severe hemoptysis related to fungus ball.

Conclusions

In a tertiary hospital, the incidence of severe hemoptysis-related events in patients with fungus ball was not low and reached 28.9%. Young patients, those with thick wall cavitary fungus ball, and those with complaints of blood-tinged sputum should be considered for early surgical treatment to prevent severe hemoptysis.

Serum developmental endothelial locus-1 is associated with severity of sepsis in animals and humans

Disruption of the endothelial glycocalyx has a prominent role in the pathophysiology of sepsis. Developmental endothelial locus-1 (Del-1) is an endothelial-derived anti-inflammatory factor. We hypothesized that degradation of the endothelial glycocalyx during sepsis may increase serum Del-1. A mouse model of sepsis was created using cecal ligation and puncture. In septic mice, the endothelial glycocalyx was nearly completely degraded, with less formation of Del-1 in the endothelium and extracellular matrix than in control mice. Serum Del-1 levels were significantly increased in the septic mice with increasing severity of sepsis. Serum Del-1 levels were also measured in 84 patients with sepsis and septic shock and in 20 control subjects. The median serum Del-1 level in patients with sepsis was significantly higher than that in healthy controls. The high Del-1 group had higher illness severity scores and contained more patients with organ dysfunction than the low Del-1 group. The 90-day mortality rate was significantly higher in the high Del-1 group than in the low Del-1 group. Multivariate analysis indicated a tendency for a high serum Del-1 level to be associated with a higher mortality risk. Increased serum Del-1 may be a novel diagnostic biomarker of sepsis and an indicator of disease severity.

Effect of adjunctive corticosteroid on 28-day mortality in neutropenic patients with septic shock

The role of adjunctive corticosteroid in septic shock remains debatable, and its role has not been assessed in neutropenic patients. We evaluated whether hydrocortisone reduces 28-day mortality in neutropenic patients with septic shock. We conducted a retrospective cohort study between January 2012 and May 2017 at a tertiary care center in South Korea. Patients who developed septic shock treated with at least one vasopressor and whose absolute neutrophil count was < 1000 cells/μL were included. Patients were classified into a steroid and a no-steroid group. The primary outcome of the study was 28-day mortality. Propensity score matching was used to adjust baseline characteristics and disease severity between the groups. Of the 287 patients analyzed, 189 were classified in the no-steroid group and 98 in the steroid group. Fifty propensity score-matched pairs were compared for the study outcomes. We found no significant difference in 28-day mortality between patients treated with and without steroid after propensity score matching (38.0% and 42.0%, respectively; p = 0.838). Incidences of pneumonia and gastrointestinal bleeding were more frequent in the steroid group, but it was not statistically significant after matching. In conclusion, adjunctive hydrocortisone was not associated with reduced 28-day mortality in neutropenic patients with septic shock.