Factors Affecting Delirium in ICU Patients

This study examined delirium severity using a delirium screening tool and analyzed the predictors, including pain, acuity, level of consciousness, fall risk, and pain score, to increase understanding of delirium and present foundational data for developing nursing interventions for delirium prevention. This was a retrospective study of 165 patients admitted to three intensive care units (ICUs). the Nursing Delirium Screening Scale (Nu-DESC) was used as a research tool to screen for delirium and measure the degree of delirium. The incidence of delirium in patients was 53.3%, and the average delirium score in the delirium group was 2.40 ± 0.56. Nu-DESC scores were significantly correlated with ICU days, ventilator days, restraint applications, the number of catheters inserted, sedative medication use, the Simplified Acute Physiology Score (SAPS III), the Morse Fall Scale (MFS), the Glasgow Coma Scale (GCS) scores, pain scores, and blood urea nitrogen (BUN). Stepwise multiple linear regression showed that the number of restraint applications, GCS score, ICU days, and BUN levels were factors influencing delirium. Based on the findings, ICU nurses should use delirium screening tools to ensure accurate delirium screening and work to reduce the incidence and degree of delirium by observing factors affecting delirium in patients.

Prognostic role of serum ammonia in patients with sepsis-associated encephalopathy without hepatic failure

Objectives

Our previous study shows that serum ammonia in sepsis patients without hepatic failure is associated with a poor prognosis. The relationship between serum ammonia level and the prognosis of sepsis-associated encephalopathy (SAE) patients without hepatic failure remains unclear. We aimed to explore the relationship between serum ammonia levels and the prognosis of patients with SAE.

Materials and methods

This study is a retrospective cohort study. We collected 465 patients with SAE admitted to the intensive care unit (ICU) from Medical Information Mart for Intensive Care IV (MIMIC IV) from 2008 to 2019. Patients with SAE were divided into a survival group (369 patients) and a non-survival group (96 patients). We used the Wilcoxon signed-rank test and the multivariate logistic regression analysis to analyze the relationship between serum ammonia levels and the prognosis of patients with SAE. R software was used to analyze the dataset.

Results

The primary outcome was the relationship between serum ammonia level and hospital mortality of SAE. The secondary outcomes were the relationship between serum ammonia level and hospital stays, simplified acute physiology score (SAPS II), Charlson, Glasgow coma scale (GCS), sequential organ failure assessment (SOFA), and lactate level of SAE. The mortality of patients with SAE was 20.6%. The serum ammonia level was not significantly associated with hospital mortality, longer hospital stays, higher SAPS II and Charlson scores, and lower GCS of patients with SAE. The serum ammonia level was associated with higher SOFA scores and lactate levels in patients with SAE. The SAPS II and Charlson scores were independent risk factors for death in patients with SAE.

Conclusion

Serum ammonia level was associated with higher SOFA scores and lactate levels in patients with SAE. In addition, the SAPS II and Charlson scores can be used to assess the prognosis of patients with SAE. Therefore, we should closely monitor serum ammonia, SAPS II, and Charlson levels in patients with SAE.

Are the conventional scoring systems efficient in predicting mortality of acute mesenteric ischemia?: Mortality estimation in patients with AMI

Acute mesenteric ischemia is a surgical emergency with high morbidity and mortality rates. Therefore, it is important to determine the prognosis for this disease. In the present study, we aimed to compare the prediction accuracy of 3 scoring systems: Acute physiology and chronic health evaluation II, sequential organ failure assessment score and simplified acute physiology score II (SAPS II). The retrospective cohort study was conducted in a university hospital. Eighty-two acute mesenteric ischemia patients were evaluated retrospectively. The mortality prediction abilities of the scoring systems were evaluated by comparing the prediction rates of > 10%, 30% and 50% and the actual mortality among survivors and non-survivors in pairs. Predicted mortality rates among survivors and non-survivors differed among the 3 classification systems. The mortality estimates of the SAPS II were closer to the actual mortality rates. Analysis of the estimated mortality rates as mortality risk limits showed that acute physiology and chronic health evaluation II was superior to sequential organ failure assessment score and SAPS II in estimating mortality rates, whereas SAPS II was more successful in detecting survivors. The estimated mortality rates of the 3 rating systems, the estimated mortality rates were higher in the non-survivor group than in the survivor group. The accuracy of the SAPS II in determining prognosis was relatively better.

Simplified Acute Physiology Score 3 Performance in Austrian COVID-19 Patients Admitted to Intensive Care Units with and without Diabetes

This study evaluated and compared the performance of simplified acute physiology score 3 (SAPS 3) for predicting in-hospital mortality in COVID-19 patients admitted to intensive care units (ICUs) with and without diabetes in Austria. The Austrian national public health institute (GÖG) data of COVID-19 patients admitted to ICUs (n = 5850) were analyzed. Three versions of SAPS 3 were used: standard equation, Central European equation, and Austrian equation customized for COVID-19 patients. The observed in-hospital mortality was 38.9%, 42.9%, and 37.3% in all, diabetes, and non-diabetes patients, respectively. The overall C-statistics was 0.69 with an insignificant (p = 0.193) difference between diabetes (0.70) and non-diabetes (0.68) patients. The Brier score was > 0.20 for all SAPS 3 equations in all cohorts. Calibration was unsatisfactory for both standard and Central European equations in all cohorts, whereas it was satisfactory for the Austrian equation in diabetes patients only. The SAPS 3 score demonstrated low discrimination and accuracy in Austrian COVID-19 patients, with an insignificant difference between diabetes and non-diabetes. All equations were miscalibrated particularly in non-diabetes patients, while the Austrian equation showed satisfactory calibration in diabetes patients only. Both uncalibrated and calibrated versions of SAPS 3 should be used with caution in COVID-19 patients.

ERCP in critically ill patients is safe and does not increase mortality

ABSTRACT

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for minimally-invasive treatment of biliary or pancreatic tract disease. When treating patients on intensive care units (ICU) with ERCP, interventionalists are faced with considerably higher morbidity compared to patients in ambulatory settings. However, data on complications and outcome of critical ill patients undergoing emergency ERCP are limited.A retrospective analysis of 102 patients treated on ICUs undergoing 121 ERCP procedures at the University Hospital of Essen, Germany between 2002 and 2016 was performed. Indications, interventional success, outcome including survival and procedure-related complications were analyzed. Patients' condition pre-ERCP was categorized by using the "Simplified Acute Physiology Score" (SAPS 3).66/102 patients (64.7%) were referred to ERCP from surgical ICU, 36/102 (35.3%) from nonsurgical ICU. The majority of patients were male (63.7%), the mean age was 54.1 ± 14.9 [21-88] years. Indications for ERCP were biliary complications after liver transplantation (n = 34, 33.3%), biliary leakage after hepatobiliary surgery (n = 32, 31.4%), and cholangitis/biliary sepsis (n = 36; 35.3%), respectively. 117/121 (96.7%) ERCPs were successful, 1 patient (1.0%) died during ERCP. Post-ERCP pancreatitis occurred in 11.8% of interventions. The median simplified acute physiology score 3 was 65 points, predicting a risk-adjusted estimated mortality of 48.8%, corresponding to an observed mortality of 52.2% (P = n.s.).ERCP is safe in critically ill patients on ICU, it does not increase overall mortality rate and has a relatively low rate of procedure-associated complications.

Outcome of patients with cirrhosis requiring mechanical ventilation in ICU

INTRODUCTION

Mortality rate of patients with cirrhosis admitted to the intensive care unit (ICU) and requiring mechanical ventilation varies between 60 and 91%. The aim of our study is to assess the prognosis of these patients, their 1-year outcome and to analyze predictive factors of long-term mortality.

METHODS

From May 2005 to May 2011, we studied 246 consecutive patients with cirrhosis requiring mechanical ventilation either at admission or during their ICU stay.

RESULTS

Alcohol was the most common etiology of the cirrhosis (69%). Bleeding related to portal hypertension (30%) and severe sepsis (33%) were the most common reasons for admission. ICU and hospital mortality were respectively 65.9% and 70.3%. Prognostic severity scores, the need for other organ support therapy, infection, and total bilirubin value at ICU admission were significantly associated with ICU mortality. Eighty-four patients (34.1%) were discharged from the ICU. Among these patients, the one-year survival was only of 32%. Logistic regression analysis, using survival at one year as the endpoint, identified two independent risk factors: the length of ventilation (odds ratio [OR] = 1.1; 95% CI, 1.0-1.2; p = 0.02) and total bilirubin at ICU discharge (OR = 1.3; 95% CI, 1.1-1.5; p = 0.006).

CONCLUSION

Patients with cirrhosis admitted to the liver ICU and who required mechanical ventilation have a poor prognosis with a 1-year mortality of 89%. At ICU discharge, a total bilirubin level higher than 64.5 μmol/L and length of ventilation higher than 9 days could help the hepatologists to identify patients at risk of death in the year following the ICU discharge.

Alteration of plasma phospholipid fatty acid profile in patients with septic shock

In septic shock patients, alterations of plasma phospholipid fatty acid profile have never been described. The purpose of this monocentric, non-interventional, observational prospective study was to describe this fatty acid profile in the early phase of septic shock in intensive care unit. Thirty-seven adult patients with septic shock were included after the first day of stay in intensive care unit, before any form of artificial nutritional support. Plasma phospholipid fatty acid composition was determined by gas chromatography. All biological data from patients with septic shock were compared with laboratory reference values. Patients presented hypocholesterolemia and hypertriglyceridemia. They had low concentrations of phospholipid fatty acids specifically n-6 and n-3 polyunsaturated fatty acids (PUFAs) with a high n-6/n-3 ratio. Plasma phospholipid PUFA concentrations were strongly correlated with cholesterolemia. PUFAs/SFAs (saturated fatty acids) and PUFAs/MUFAs (monounsaturated fatty acids) ratios were low because of low percentage of n-6 and n-3 PUFAs and high percentage of SFAs and MUFAs. Low levels of plasma long chain PUFAs (≥20 carbons) were significantly associated with mortality at 28th day. In conclusion, plasma phospholipid FA profile of septic patients is very characteristic, close to that of acute respiratory distress syndrome and mortality is associated with long chain PUFA decrease. This profile could be explained by numerous non-exclusive physio-pathological processes 1) an activation of hepatic de novo lipogenesis that could contribute to hepatic steatosis, 2) an elevated adipose tissue lipolysis, 3) an increased free radical attack of FA by oxidative stress, 4) an over-production of inflammatory lipid mediators.

Modeling serum level of s100β and bispectral index to predict outcome after cardiac arrest

OBJECTIVES

This study was designed to evaluate multimodal prognostication in patients after cardiac arrest (CA).

BACKGROUND

Accurate methods to predict outcome after CA are lacking.

METHODS

Seventy-five patients with CA treated with therapeutic hypothermia after cardiac resuscitation were enrolled in this prospective observational study. Serum levels of neuron-specific enolase (NSE) and neuron-enriched S100 beta (S100β) were measured 48 h after CA. Bispectral index (BIS) was continuously monitored during the first 48 h after CA. The primary endpoint was neurological outcome, as defined by the cerebral performance category (CPC) at 6-month follow-up: scores 1 or 2 indicated good outcome, and scores 3 to 5, poor outcome. The secondary endpoint was survival.

RESULTS

A total of 46 (61%) patients survived at 6 months and 41 (55%) patients had CPC 1 or 2. Levels of NSE and S100β were higher in patients with poor outcomes compared with patients with good outcomes (4-fold and 10-fold, respectively; p < 0.001). BIS was lower in patients with poor outcomes (10-fold; p < 0.001). NSE, S100β, or BIS alone predicted neurological outcome, with areas under the receiver-operating characteristic curve (AUC) above 0.80. Combined determination of S100β and BIS had an incremental predictive value (AUC: 0.95). S100β improved discriminations based on BIS (p = 0.0008), and BIS improved discriminations based on S100β (p < 10(-5)). Patients with S100β level above 0.03 μg/l and BIS below 5.5 had a 3.6-fold higher risk of poor neurological outcome (p < 0.0001). S100β and BIS predicted 6-month mortality (log-rank statistic: 50.41; p < 0.001).

CONCLUSIONS

Combined determination of serum level of S100β and BIS monitoring accurately predicts outcome after CA.