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Lancia G, Varkila MRJ, Cremer OL, Spitoni C. Two-step interpretable modeling of ICU-AIs. Artif Intell Med 2024; 151:102862. [PMID: 38579437 DOI: 10.1016/j.artmed.2024.102862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 03/25/2024] [Accepted: 03/25/2024] [Indexed: 04/07/2024]
Abstract
We present a novel methodology for integrating high resolution longitudinal data with the dynamic prediction capabilities of survival models. The aim is two-fold: to improve the predictive power while maintaining the interpretability of the models. To go beyond the black box paradigm of artificial neural networks, we propose a parsimonious and robust semi-parametric approach (i.e., a landmarking competing risks model) that combines routinely collected low-resolution data with predictive features extracted from a convolutional neural network, that was trained on high resolution time-dependent information. We then use saliency maps to analyze and explain the extra predictive power of this model. To illustrate our methodology, we focus on healthcare-associated infections in patients admitted to an intensive care unit.
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Affiliation(s)
- G Lancia
- Mathematics Department, Utrecht University, Budapestlaan, 6, Utrecht, 3584CD, The Netherlands.
| | - M R J Varkila
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht, 3584 CG, The Netherlands
| | - O L Cremer
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht, 3584 CG, The Netherlands
| | - C Spitoni
- Mathematics Department, Utrecht University, Budapestlaan, 6, Utrecht, 3584CD, The Netherlands
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Hyder S, Tang R, Huang R, Ludwig A, Scott K, Nadig N. Implementation of an Interdisciplinary Transfer Huddle Intervention for Prolonged Wait Times During Inter-ICU Transfer. Jt Comm J Qual Patient Saf 2024; 50:371-376. [PMID: 38378394 DOI: 10.1016/j.jcjq.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND ICU transfers from a regional to a tertiary-level hospital are initiated typically for a higher level of care. Extended transfer wait times can negatively affect survival, length of stay (LOS), and cost. METHODS In this prospective single-center study, the subjects were adult ICU patients admitted to regional hospitals between January and October 2022, for whom a request was made to transfer to a tertiary-level medical ICU. The authors developed and implemented an interdisciplinary transfer huddle intervention (THI) with the goal of reducing wait times by providing a consistent channel of communication between key stakeholders. The primary outcome was the number of hours elapsed between transfer request and the time of transfer to the tertiary hospital. Secondary outcomes included in-hospital mortality, discharge to home, ICU LOS, and hospital LOS. Data were abstracted from electronic health records and periods before (January to June 2022) and after (June to October 2022) the intervention were compared. Data were analyzed using logistic regression or negative binomial regression, adjusting for patient demographic and clinical characteristics. ICU fellows also completed a daily survey about barriers they perceived to the THI application. RESULTS During the study period, 76 patients were transferred. The THI was completed 75.0% of the time. There were no statistically significant differences in the primary and secondary outcomes before and after the intervention. The top perceived barriers to transfer were lack of physical beds (50.0%) and staffing limitations (37.5%). CONCLUSION The authors successfully developed and implemented a transfer huddle to ensure consistent interdisciplinary communication for patients being transferred between ICUs and identified barriers to such transfer. However, transfer times and patient outcomes were not significantly different after the change. Future studies should consider staffing challenges, hospital capacity, and the role of dedicated transfer teams in in decreasing inter-ICU transfer wait times.
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Lin SH, Chen WT, Tsai MH, Liu LT, Kuo WL, Lin YT, Wang SF, Chen BH, Lee CH, Huang CH, Chien RN. A novel prognostic model to predict mortality in patients with acute-on-chronic liver failure in intensive care unit. Intern Emerg Med 2024; 19:721-730. [PMID: 38386096 DOI: 10.1007/s11739-024-03536-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 01/11/2024] [Indexed: 02/23/2024]
Abstract
Acute-on-chronic liver failure (ACLF) implies high short-term mortality rates and usually requires intensive care unit (ICU) admission. Proper prognosis for these patients is crucial for early referral for liver transplantation. The superiority of CLIF-C ACLF score in Asian patients with ACLF admitted to an ICU remains inconclusive when compared to other scoring systems. The purpose of the study is (i) to compare the predictive performance of original MELD, MELD-Lactate, CLIF-C ACLF, CLIF-C ACLF-Lactate, and APACHE-II scores for short-term mortality assessment. (ii) to build and validate a novel scoring system and to compare its predictive performance to that of the original five scores. Two hundred sixty-five consecutive cirrhotic patients with ACLF who were admitted to our ICU were enrolled. The prognostic values for mortality were assessed by ROC analysis. A novel model was developed and internally validated using fivefold cross-validation. Alcohol abuse was identified as the primary etiology of cirrhosis. The AUROC of the five prognostic scores were not significantly superior to each other in predicting 1-month and 3-month mortality. The newly developed prognostic model, incorporating age, alveolar-arterial gradient (A-a gradient), BUN, total bilirubin level, INR, and HE grades, exhibited significantly improved performance in predicting 1-month and 3-month mortality with AUROC of 0.863 and 0.829, respectively, as compared to the original five prognostic scores. The novel ACLF model seems to be superior to the original five scores in predicting short-term mortality in ACLF patients admitted to an ICU. Further rigorous validation is required.
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Affiliation(s)
- Shih-Hua Lin
- Department of Gastroenterology and Hepatology, New Taipei Municipal TuCheng Hospital, Tucheng, New Taipei City, 236, Taiwan
| | - Wei-Ting Chen
- Division of Hepatology, Department of Gastroenterology and Hepatology, Linkou Chang-Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, 333, Taiwan
| | - Ming-Hung Tsai
- Division of Hepatology, Department of Gastroenterology and Hepatology, Linkou Chang-Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, 333, Taiwan
| | - Li-Tong Liu
- Division of Hepatology, Department of Gastroenterology and Hepatology, Linkou Chang-Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Wei-Liang Kuo
- Division of Hepatology, Department of Gastroenterology and Hepatology, Linkou Chang-Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Yan-Ting Lin
- Division of Hepatology, Department of Gastroenterology and Hepatology, Linkou Chang-Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Sheng-Fu Wang
- Division of Hepatology, Department of Gastroenterology and Hepatology, Linkou Chang-Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Bo-Huan Chen
- Division of Hepatology, Department of Gastroenterology and Hepatology, Linkou Chang-Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Cheng-Han Lee
- Division of Hepatology, Department of Gastroenterology and Hepatology, Linkou Chang-Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Chien-Hao Huang
- Division of Hepatology, Department of Gastroenterology and Hepatology, Linkou Chang-Gung Memorial Hospital, Taoyuan, 333, Taiwan.
- College of Medicine, Chang-Gung University, Taoyuan, 333, Taiwan.
| | - Rong-Nan Chien
- Division of Hepatology, Department of Gastroenterology and Hepatology, Linkou Chang-Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, 333, Taiwan
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Pfäfflin F, Stegemann MS, Heim KM, Achterberg S, Pfitzner U, Götze L, Oesterhelweg L, Suttorp N, Herzog C, Stadtmann B, Uhrig A. Preparing for patients with high-consequence infectious diseases: Example of a high-level isolation unit. PLoS One 2022; 17:e0264644. [PMID: 35239726 PMCID: PMC8893674 DOI: 10.1371/journal.pone.0264644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/14/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction
Patients with high-consequence infectious diseases (HCID) are rare in Western Europe. However, high-level isolation units (HLIU) must always be prepared for patient admission. Case fatality rates of HCID can be reduced by providing optimal intensive care management. We here describe a single centre’s preparation, its embedding in the national context and the challenges we faced during the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic.
Methods
Ten team leaders organize monthly whole day trainings for a team of doctors and nurses from the HLIU focusing on intensive care medicine. Impact and relevance of training are assessed by a questionnaire and a perception survey, respectively. Furthermore, yearly exercises with several partner institutions are performed to cover different real-life scenarios. Exercises are evaluated by internal and external observers. Both training sessions and exercises are accompanied by intense feedback.
Results
From May 2017 monthly training sessions were held with a two-month and a seven-month break due to the first and second wave of the SARS-CoV-2 pandemic, respectively. Agreement with the statements of the questionnaire was higher after training compared to before training indicating a positive effect of training sessions on competence. Participants rated joint trainings for nurses and doctors at regular intervals as important. Numerous issues with potential for improvement were identified during post processing of exercises. Action plans for their improvement were drafted and as of now mostly implemented. The network of the permanent working group of competence and treatment centres for HCID (Ständiger Arbeitskreis der Kompetenz- und Behandlungszentren für Krankheiten durch hochpathogene Erreger (STAKOB)) at the Robert Koch-Institute (RKI) was strengthened throughout the SARS-CoV-2 pandemic.
Discussion
Adequate preparation for the admission of patients with HCID is challenging. We show that joint regular trainings of doctors and nurses are appreciated and that training sessions may improve perceived skills. We also show that real-life scenario exercises may reveal additional deficits, which cannot be easily disclosed in training sessions. Although the SARS-CoV-2 pandemic interfered with our activities the enhanced cooperation among German HLIU during the pandemic ensured constant readiness for the admission of HCID patients to our or to collaborating HLIU. This is a single centre’s experience, which may not be generalized to other centres. However, we believe that our work may address aspects that should be considered when preparing a unit for the admission of patients with HCID. These may then be adapted to the local situations.
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Affiliation(s)
- Frieder Pfäfflin
- Department for Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- * E-mail:
| | - Miriam Songa Stegemann
- Department for Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Katrin Moira Heim
- Department for Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Stephan Achterberg
- Department for Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Ursula Pfitzner
- Department for Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Louise Götze
- Department for Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Lars Oesterhelweg
- Institute of Legal Medicine and Forensic Sciences, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Norbert Suttorp
- Department for Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Christian Herzog
- Centre for Biological Threats, Strategy and Incident Response, Robert Koch-Institute, Berlin, Germany
| | - Benjamin Stadtmann
- Department for Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Alexander Uhrig
- Department for Infectious Diseases and Respiratory Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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Roche E, Lim C, Sayma M, Navaratnam A, Davis PJ, Ramnarayan P, Fraser J, Kenny S. Learning lessons from the paediatric critical care response to the SARS-CoV-2 pandemic in England and Wales: a qualitative study. Arch Dis Child 2022; 107:e6. [PMID: 34417188 PMCID: PMC8384492 DOI: 10.1136/archdischild-2020-320662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 08/03/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To explore the experiences of clinical leads in paediatric critical care units (PCCUs) in England and Wales during the reorganisation of services in the initial surge of the SARS-CoV-2 pandemic and to learn lessons for future surges and service planning. METHODS A qualitative study design using semistructured interviews via virtual conferencing was conducted with consultant clinical leads and lead nurses covering 21 PCCUs. Interviews were conducted over a period of 2 weeks, 2 months after the initial SARS-CoV-2 surge. Interview notes underwent thematic analysis. RESULTS Thematic analysis revealed six themes: leadership, management and planning; communication; workforce development and training; innovation; workforce experience; and infection prevention and control. Leadership was facilitated through clinician-led local autonomy for decision-making and services were better delivered when the workforce was empowered to be flexible in their response. Communication was preferred through collaborative management structures. Further lessons include recognising workforce competencies in surge preparations, the use of virtual technology in facilitating training and meetings, the importance of supporting the well-being of the workforce and the secondary consequences of personal protective equipment use. CONCLUSIONS During the 2020 SARS-CoV-2 pandemic, an agile response to a rapidly changing situation was enabled through effective clinical leadership and an adaptive workforce. Open systems of communication across senior clinical and management teams facilitated service planning. Support for all members of the workforce through implementation of appropriate and innovative education and well-being solutions was vital in sustaining resilience. This learning supports planning for future surge capacity across paediatric critical care locally and nationally.
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Affiliation(s)
- Emma Roche
- Birmingham Women's and Children's Hospitals NHS Foundation Trust, Birmingham, UK
| | - Chun Lim
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - Peter J Davis
- Bristol Royal Hospital for Children, Paediatric Intensive Care Unit, Bristol, UK
- NHS England & NHS Improvement, London, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, London, UK
- Paediatric Critical Care Society, London, UK
| | - James Fraser
- Bristol Royal Hospital for Children, Paediatric Intensive Care Unit, Bristol, UK
- Paediatric Critical Care Society, London, UK
| | - Simon Kenny
- Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Medical Director for Children and Young People, NHS England & NHS Improvement, London, UK
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de Vos J, Visser LA, de Beer AA, Fornasa M, Thoral PJ, Elbers PWG, Cinà G. The Potential Cost-Effectiveness of a Machine Learning Tool That Can Prevent Untimely Intensive Care Unit Discharge. Value Health 2022; 25:359-367. [PMID: 35227446 DOI: 10.1016/j.jval.2021.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/06/2021] [Accepted: 06/29/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The machine learning prediction model Pacmed Critical (PC), currently under development, may guide intensivists in their decision-making process on the most appropriate time to discharge a patient from the intensive care unit (ICU). Given the financial pressure on healthcare budgets, this study assessed whether PC has the potential to be cost-effective compared with standard care, without the use of PC, for Dutch patients in the ICU from a societal perspective. METHODS A 1-year, 7-state Markov model reflecting the ICU care pathway and incorporating the PC decision tool was developed. A hypothetical cohort of 1000 adult Dutch patients admitted in the ICU was entered in the model. We used the literature, expert opinion, and data from Amsterdam University Medical Center for model parameters. The uncertainty surrounding the incremental cost-effectiveness ratio was assessed using deterministic and probabilistic sensitivity analyses and scenario analyses. RESULTS PC was a cost-effective strategy with an incremental cost-effectiveness ratio of €18 507 per quality-adjusted life-year. PC remained cost-effective over standard care in multiple scenarios and sensitivity analyses. The likelihood that PC will be cost-effective was 71% at a willingness-to-pay threshold of €30 000 per quality-adjusted life-year. The key driver of the results was the parameter "reduction in ICU length of stay." CONCLUSIONS We showed that PC has the potential to be cost-effective for Dutch ICUs in a time horizon of 1 year. This study is one of the first cost-effectiveness analyses of a machine learning device. Further research is needed to validate the effectiveness of PC, thereby focusing on the key parameter "reduction in ICU length of stay" and potential spill-over effects.
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Affiliation(s)
- Juliette de Vos
- Pacmed B.V., Amsterdam, The Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Laurenske A Visser
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | - Patrick J Thoral
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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Baheti AD, Nayak P. Covid-19 in India: Oxygen shortages and a real world trolley problem. BMJ 2022; 376:o369. [PMID: 35149512 DOI: 10.1136/bmj.o369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Akshay D Baheti
- Department of Radiodiagnosis, Tata Memorial Hospital, TMC, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Prakash Nayak
- Homi Bhabha National Institute, Mumbai, India
- Department of Orthopedic Oncology, Tata Memorial Hospital, TMC, Mumbai, India
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Juschten J, Bos LDJ, de Grooth HJ, Beuers U, Girbes ARJ, Juffermans NP, Loer SA, van der Poll T, Cremer OL, Bonten MJM, Schultz MJ, Tuinman PR. Incidence, Clinical Characteristics and Outcomes of Early Hyperbilirubinemia in Critically Ill Patients: Insights From the MARS Study. Shock 2022; 57:161-167. [PMID: 34238904 PMCID: PMC8757589 DOI: 10.1097/shk.0000000000001836] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/19/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the incidence, clinical characteristics and outcomes of early hyperbilirubinemia in critically ill patients. DESIGN AND SETTING This is a post hoc analysis of a prospective multicenter cohort study. PATIENTS Patients with measured bilirubin levels within the first 2 days after ICU admission were eligible. Patients with liver cirrhosis were excluded. ENDPOINTS The primary endpoint was the incidence of early hyperbilirubinemia, defined as bilirubin ≥33 μmol/L within 2 days after ICU admission. Secondary endpoints included clinical characteristics of patients with versus patients without early hyperbilirubinemia, and outcomes up to day 30. RESULTS Of 4,836 patients, 559 (11.6%) patients had early hyperbilirubinemia. Compared to patients without early hyperbilirubinemia, patients with early hyperbilirubinemia presented with higher severity of illness scores, and higher incidences of sepsis and organ failure. After adjustment for confounding variables, early hyperbilirubinemia remained associated with mortality at day 30 (odds ratio, 1.31 [95%-confidence interval 1.06-1.60]; P = 0.018). Patients with early hyperbilirubinemia and thrombocytopenia (interaction P-value = 0.005) had a higher likelihood of death within 30 days (odds ratio, 2.61 [95%-confidence interval 2.08-3.27]; P < 0.001) than patients with early hyperbilirubinemia and a normal platelet count (odds ratio, 1.09 [95%-confidence interval 0.75-1.55]; P = 0.655). CONCLUSIONS Early hyperbilirubinemia occurs frequently in the critically ill, and these patients present with higher disease severity and more often with sepsis and organ failures. Early hyperbilirubinemia has an association with mortality, albeit this association was only found in patients with concomitant thrombocytopenia.
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Affiliation(s)
- Jenny Juschten
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
- Department of Pulmonology, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Armand R. J. Girbes
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care Medicine, OLVG Hospital, Amsterdam, The Netherlands
| | - Stephan A. Loer
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Division of Infectious Diseases, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Olaf L. Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc J. M. Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Prescott BR, Saglam H, Duskin JA, Miller MI, Thakur AS, Gholap EA, Hutch MR, Smirnakis SM, Zafar SF, Dupuis J, Benjamin EJ, Greer DM, Ong CJ. Anisocoria and Poor Pupil Reactivity by Quantitative Pupillometry in Patients With Intracranial Pathology. Crit Care Med 2022; 50:e143-e153. [PMID: 34637415 PMCID: PMC8810747 DOI: 10.1097/ccm.0000000000005272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To describe the prevalence and associated risk factors of new onset anisocoria (new pupil size difference of at least 1 mm) and its subtypes: new onset anisocoria accompanied by abnormal and normal pupil reactivities in patients with acute neurologic injuries. DESIGN We tested the association of patients who experienced new onset anisocoria subtypes with degree of midline shift using linear regression. We further explored differences between quantitative pupil characteristics associated with first-time new onset anisocoria and nonnew onset anisocoria at preceding observations using mixed effects logistic regression, adjusting for possible confounders. SETTING All quantitative pupil observations were collected at two neuro-ICUs by nursing staff as standard of care. PATIENTS We conducted a retrospective two-center study of adult patients with intracranial pathology in the ICU with at least a 24-hour stay and three or more quantitative pupil measurements between 2016 and 2018. MEASUREMENTS AND MAIN RESULTS We studied 221 patients (mean age 58, 41% women). Sixty-three percent experienced new onset anisocoria. New onset anisocoria accompanied by objective evidence of abnormal pupil reactivity occurring at any point during hospitalization was significantly associated with maximum midline shift (β = 2.27 per mm; p = 0.01). The occurrence of new onset anisocoria accompanied by objective evidence of normal pupil reactivity was inversely associated with death (odds ratio, 0.34; 95% CI, 0.16-0.71; p = 0.01) in adjusted analyses. Subclinical continuous pupil size difference distinguished first-time new onset anisocoria from nonnew onset anisocoria in up to four preceding pupil observations (or up to 8 hr prior). Minimum pupil reactivity between eyes also distinguished new onset anisocoria accompanied by objective evidence of abnormal pupil reactivity from new onset anisocoria accompanied by objective evidence of normal pupil reactivity prior to first-time new onset anisocoria occurrence. CONCLUSIONS New onset anisocoria occurs in over 60% of patients with neurologic emergencies. Pupil reactivity may be an important distinguishing characteristic of clinically relevant new onset anisocoria phenotypes. New onset anisocoria accompanied by objective evidence of abnormal pupil reactivity was associated with midline shift, and new onset anisocoria accompanied by objective evidence of normal pupil reactivity had an inverse relationship with death. Distinct quantitative pupil characteristics precede new onset anisocoria occurrence and may allow for earlier prediction of neurologic decline. Further work is needed to determine whether quantitative pupillometry sensitively/specifically predicts clinically relevant anisocoria, enabling possible earlier treatments.
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Affiliation(s)
- Brenton R. Prescott
- Boston Medical Center, 1 Boston Medical Center Pl, Boston, MA 02118
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118
- Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115
| | - Hanife Saglam
- Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115
| | - Jonathan A. Duskin
- Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115
- Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114
| | - Matthew I. Miller
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118
| | - Arnav S. Thakur
- Boston Medical Center, 1 Boston Medical Center Pl, Boston, MA 02118
| | - Eesha A. Gholap
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118
| | | | - Stelios M. Smirnakis
- Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115
| | - Sahar F. Zafar
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115
- Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114
| | - Josée Dupuis
- Boston University School of Public Health, 715 Albany St, Boston, MA 02118
| | - Emelia J. Benjamin
- Boston Medical Center, 1 Boston Medical Center Pl, Boston, MA 02118
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118
- Boston University School of Public Health, 715 Albany St, Boston, MA 02118
| | - David M. Greer
- Boston Medical Center, 1 Boston Medical Center Pl, Boston, MA 02118
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118
| | - Charlene J. Ong
- Boston Medical Center, 1 Boston Medical Center Pl, Boston, MA 02118
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118
- Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115
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Gardashkhani S, Ajri-Khameslou M, Heidarzadeh M, Rajaei Sedigh S. Post-Intensive Care Syndrome in Covid-19 Patients Discharged From the Intensive Care Unit. J Hosp Palliat Nurs 2021; 23:530-538. [PMID: 34534991 PMCID: PMC8560146 DOI: 10.1097/njh.0000000000000789] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patients with Covid-19, after discharge from the intensive care unit (ICU), experience some psychological, physical, and cognitive disorders, which is known as the post-intensive care syndrome and has adverse effects on patients and their families. The aim of this study was to evaluate the post-intensive care syndrome and its predictors in Covid-19 patients discharged from the ICU. In this study, 84 Covid-19 patients discharged from the ICU were selected by census method based on inclusion and exclusion criteria. After completing the demographic information, the Healthy Aging Brain Care Monitor Self Report Tool was used to assess post-intensive care syndrome. Sixty-nine percent of participants experienced different degrees of post-intensive care syndrome, and its mean score was 8.86 ± 12.50; the most common disorder was related to the physical dimension. Among individual social variables, age and duration after discharge were able to predict 12.3% and 8.4% of the variance of post-intensive care syndrome, respectively. Covid-19 patients who are admitted to the ICU, after discharge from the hospital, face cognitive, psychological, and functional disorders, and there is a need for planning to prevent, follow up, and care for them by health care providers in the hospice and palliative care centers.
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11
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Foley OW, Chisari G, Curran J, Berkowitz LR. Enhancing the Interprofessional Learning Environment: An Orientation of ICU Nurses to Effective Team Building and Their Impact on the Professional Development of the Young Physician. Acad Med 2021; 96:S183. [PMID: 34705681 DOI: 10.1097/acm.0000000000004337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Olivia W Foley
- Author affiliations: O.W. Foley, L.R. Berkowitz, Massachusetts General Hospital, Harvard Medical School
| | - Gino Chisari
- G. Chisari, J. Curran, Norman Night Nursing Center for Clinical and Professional Development, Massachusetts General Hospital
| | - Jennifer Curran
- G. Chisari, J. Curran, Norman Night Nursing Center for Clinical and Professional Development, Massachusetts General Hospital
| | - Lori R Berkowitz
- Author affiliations: O.W. Foley, L.R. Berkowitz, Massachusetts General Hospital, Harvard Medical School
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Vranas KC, Golden SE, Mathews KS, Schutz A, Valley TS, Duggal A, Seitz KP, Chang SY, Nugent S, Slatore CG, Sullivan DR, Hough CL. The Influence of the COVID-19 Pandemic on ICU Organization, Care Processes, and Frontline Clinician Experiences: A Qualitative Study. Chest 2021; 160:1714-1728. [PMID: 34062115 PMCID: PMC8164514 DOI: 10.1016/j.chest.2021.05.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic resulted in unprecedented adjustments to ICU organization and care processes globally. RESEARCH QUESTIONS Did hospital emergency responses to the COVID-19 pandemic differ depending on hospital setting? Which strategies worked well to mitigate strain as perceived by intensivists? STUDY DESIGN AND METHODS Between August and November 2020, we carried out semistructured interviews of intensivists from tertiary and community hospitals across six regions in the United States that experienced early or large surges of COVID-19 patients, or both. We identified themes of hospital emergency responses using the four S framework of acute surge planning: space, staff, stuff, system. RESULTS Thirty-three intensivists from seven tertiary and six community hospitals participated. Clinicians across both settings believed that canceling elective surgeries was helpful to increase ICU capabilities and that hospitals should establish clearly defined thresholds at which surgeries are limited during future surge events. ICU staff was the most limited resource; staff shortages were improved by the use of tiered staffing models, just-in-time training for non-ICU clinicians, designated treatment teams, and deployment of trainees. Personal protective equipment (PPE) shortages and reuse were widespread, causing substantial distress among clinicians; hands-on PPE training was helpful to reduce clinicians' anxiety. Transparency and involvement of frontline clinicians as stakeholders were important components of effective emergency responses and helped to maintain trust among staff. INTERPRETATION We identified several strategies potentially to mitigate strain as perceived by intensivists working in both tertiary and community hospital settings. Our study also demonstrated the importance of trust and transparency between frontline staff and hospital leadership as key components of effective emergency responses during public health crises.
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Affiliation(s)
- Kelly C Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR; Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR; Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Sara E Golden
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amanda Schutz
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Kevin P Seitz
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | - Steven Y Chang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan-UCLA Medical Center, Los Angeles, CA
| | - Shannon Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR; Department of Psychiatry, Oregon Health & Science University, Portland, OR
| | - Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR; Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR
| | - Donald R Sullivan
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR; Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR; Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | - Catherine L Hough
- Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR
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13
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Edsall A, Howard S, Dewey EN, Siegel T, Zonies D, Brasel K, Cook MR, Nagengast AK. Critical decisions in the trauma intensive care unit: Are we practicing primary palliative care? J Trauma Acute Care Surg 2021; 91:886-890. [PMID: 34695065 DOI: 10.1097/ta.0000000000003324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Devastating injuries require both urgent assessment by a trauma service and early attention to patients' goals of care (GOC). American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines recommend an initial palliative assessment within 24 hours of admission and family meeting, if needed, within 72 hours. We hypothesize that a primary palliative care-based practice improves adherence to TQIP guidelines in trauma patients. METHODS All adult trauma patients who died while inpatient from January 2014 to December 2018 were reviewed. Timing of GOC discussions, transition to comfort measures only (CMO), and the utilization of specialty palliative services were analyzed with univariate analysis. RESULTS During the study period, 415 inpatients died. Median Injury Severity Score was 26 (interquartile range [IQR], 17-34), median age was 67 years (IQR, 51-81 years), and 72% (n = 299) transitioned to CMO before death. Documented GOC discussions increased from 77% of patients in 2014 to 95% of patients in 2018 (p < 0.001), and in 2018, the median time to the first GOC discussion was 15 hours (IQR, 7- 24 hours). Specialty palliative care was consulted in 7% of all patients. Of patients who had at least one GOC discussion, 98% were led by the trauma intensive care unit (TICU) team. Median time from admission to first GOC discussion was 27 hours (IQR, 6-91 hours). Median number of GOC discussions was 1 (IQR, 1-2). Median time to CMO after the final GOC discussion was 0 hours (IQR, 0-3). Median time to death after transition to CMO was 4 hours (IQR, 1-18 hours). CONCLUSION Of those who died during index admission, we demonstrated significant improvement in adherence to American College of Surgeons TQIP palliative guidelines across the 5-year study period, with the TICU team guiding the majority of GOC discussions. Our TICU team has developed an effective primary palliative care approach, selectively consulting specialty palliative care only when needed. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Affiliation(s)
- Andrew Edsall
- From the Department of Surgery (A.E., S.H., E.N.D., T.S., D.Z., K.B., M.R.C., A.K.N.), Oregon Health and Science University; and Operative Care Division (A.K.N.), VA Portland Medical Center, Portland, Oregon
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Abstract
OBJECTIVE To explore the predictors of knowledge of pressure injury (PI) prevention, attitudes on PI prevention, organization support for PI prevention, and the influence of a healthy work environment (HWE) on PI prevention practices among ICU nurses in China. METHODS A descriptive, predictive, online survey was conducted among 510 ICU nurses in Guizhou province, China. A PI prevention knowledge questionnaire, PI prevention attitude questionnaire, organizational support for PI prevention questionnaire, HWE assessment tool, and PI prevention practice questionnaire were used for data collection. A hierarchical regression analysis was used to determine the influence of certain predictive factors. RESULTS An HWE, organizational support for PI prevention, and positive attitudes toward PI prevention were significant predictors of good practice regarding PI prevention. However, knowledge of PI prevention was not a significant predictor. CONCLUSIONS To achieve optimal nursing quality in terms of PI prevention, hospital and nursing administrators should develop strategies or interventions to create and sustain an HWE and supportive organizational culture for ICU nurses and enhance positive attitudes toward PI prevention.
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Affiliation(s)
- Li Hu
- In the Faculty of Nursing, Prince of Songkla University, Hatyai, Songkhla, Thailand, Li Hu, BSN, RN, is Master's Student, Nursing Science in Adult and Gerontological Nursing (International Program); Wipa Sae-Sia, PhD, RN, is Associate Professor, Department of Adult and Elderly Nursing; and Luppana Kitrungrote, PhD, RN, is Assistant Professor, Department of Adult and Elderly Nursing. Acknowledgment: This study was conducted as partial fulfillment of the requirements of the first author for the master's degree of nursing program and has received financial support from Thailand's Education Hub for Southern Region of ASEAN Countries Scholarship through Prince of Songkla University, Thailand. The authors have disclosed no other financial relationships related to this article. Submitted September 11, 2020; accepted in revised form November 24, 2020; published online ahead of print September 2, 2021
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15
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Villar J, González-Martín JM, Ambrós A, Mosteiro F, Martínez D, Fernández L, Soler JA, Parra L, Solano R, Soro M, Del Campo R, González-Luengo RI, Civantos B, Montiel R, Pita-García L, Vidal A, Añón JM, Ferrando C, Díaz-Domínguez FJ, Mora-Ordoñez JM, Fernández MM, Fernández C, Fernández RL, Rodríguez-Suárez P, Steyerberg EW, Kacmarek RM. Stratification for Identification of Prognostic Categories In the Acute RESpiratory Distress Syndrome (SPIRES) Score. Crit Care Med 2021; 49:e920-e930. [PMID: 34259448 DOI: 10.1097/ccm.0000000000005142] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To develop a scoring model for stratifying patients with acute respiratory distress syndrome into risk categories (Stratification for identification of Prognostic categories In the acute RESpiratory distress syndrome score) for early prediction of death in the ICU, independent of the underlying disease and cause of death. DESIGN A development and validation study using clinical data from four prospective, multicenter, observational cohorts. SETTING A network of multidisciplinary ICUs. PATIENTS One-thousand three-hundred one patients with moderate-to-severe acute respiratory distress syndrome managed with lung-protective ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The study followed Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis guidelines for prediction models. We performed logistic regression analysis, bootstrapping, and internal-external validation of prediction models with variables collected within 24 hours of acute respiratory distress syndrome diagnosis in 1,000 patients for model development. Primary outcome was ICU death. The Stratification for identification of Prognostic categories In the acute RESpiratory distress syndrome score was based on patient's age, number of extrapulmonary organ failures, values of end-inspiratory plateau pressure, and ratio of Pao2 to Fio2 assessed at 24 hours of acute respiratory distress syndrome diagnosis. The pooled area under the receiver operating characteristic curve across internal-external validations was 0.860 (95% CI, 0.831-0.890). External validation in a new cohort of 301 acute respiratory distress syndrome patients confirmed the accuracy and robustness of the scoring model (area under the receiver operating characteristic curve = 0.870; 95% CI, 0.829-0.911). The Stratification for identification of Prognostic categories In the acute RESpiratory distress syndrome score stratified patients in three distinct prognostic classes and achieved better prediction of ICU death than ratio of Pao2 to Fio2 at acute respiratory distress syndrome onset or at 24 hours, Acute Physiology and Chronic Health Evaluation II score, or Sequential Organ Failure Assessment scale. CONCLUSIONS The Stratification for identification of Prognostic categories In the acute RESpiratory distress syndrome score represents a novel strategy for early stratification of acute respiratory distress syndrome patients into prognostic categories and for selecting patients for therapeutic trials.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Jesús M González-Martín
- Division of Biostatistics, Research Unit, Hospital Universitario Dr. Negrín, Las Palmas, Spain
| | - Alfonso Ambrós
- Intensive Care Unit, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Fernando Mosteiro
- Intensive Care Unit, Hospital Universitario A Coruña, La Coruña, Spain
| | - Domingo Martínez
- Intensive Care Unit, Hospital Universitario Virgen de Arrixaca, Murcia, Spain
| | - Lorena Fernández
- Intensive Care Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Juan A Soler
- Intensive Care Unit, Hospital Universitario Virgen de Arrixaca, Murcia, Spain
| | - Laura Parra
- Intensive Care Unit, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Rosario Solano
- Intensive Care Unit, Hospital Virgen de la Luz, Cuenca, Spain
| | - Marina Soro
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Rafael Del Campo
- Intensive Care Unit, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | | | - Belén Civantos
- Intensive Care Unit, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - Raquel Montiel
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Santa Cruz de Tenerife, Spain
| | - Lidia Pita-García
- Intensive Care Unit, Hospital Universitario A Coruña, La Coruña, Spain
| | - Anxela Vidal
- Intensive Care Unit, Fundación Hospital Universitario Jiménez Díaz, Madrid, Spain
| | - José M Añón
- CIBER de Enfermedades Respiratorias, Instituto Salud Carlos III, Madrid, Spain
- Intensive Care Unit, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - Carlos Ferrando
- CIBER de Enfermedades Respiratorias, Instituto Salud Carlos III, Madrid, Spain
- Department of Anesthesiology and Critical Care, Hospital Clinic, Institut D'investigació August Pi i Sunyer, Barcelona, Spain
| | | | - Juan M Mora-Ordoñez
- Intensive Care Unit, Hospital Regional Universitario de Málaga Carlos Haya, Málaga, Spain
| | - M Mar Fernández
- Intensive Care Unit, Hospital Universitario Mutua Terrassa, Terrassa, Barcelona, Spain
| | - Cristina Fernández
- Research Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Rosa L Fernández
- CIBER de Enfermedades Respiratorias, Instituto Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Pedro Rodríguez-Suárez
- Department of Thoracic Surgery, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Robert M Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, Boston, MA
- Department of Anesthesiology, Harvard University, Boston, MA
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Abstract
OBJECTIVES To study memories of ICU following discharge, their associations, and impact on mental health and quality of life in a low- and middle-income country. DESIGN Prospective observational cohort; data on memories (pain, fear, nightmare, factual), clinical and demographic variables, anxiety-depression, posttraumatic stress symptoms, and quality of life were collected 0, 7, 14, 30, 90, and 180 days post discharge. Home visits for assessment minimized loss to follow-up. Linear mixed-models and regression analyses were used to estimate adjusted effects of memories controlling for age, sex, time, and severity of illness. SETTING Twenty-five bedded ICU of a tertiary care center in East India. PATIENTS Adult ICU survivors between January 2017 and July 2018 able to communicate their memories. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS Final sample consisted of 322 patients who completed 180 days follow-up. Pain, fear, factual, and nightmare memories dropped from 85%, 56%, 55%, and 45% at discharge to less than or equal to 5% at 180 days. Patients with gaps in ICU memory had worse anxiety-depression, posttraumatic stress symptoms, and quality of life at all follow-up points. Sedation (odds ratio, 0.54; CI, 0.4-0.7), steroids (odds ratio, 0.47; CI, 0.3-0.8), benzodiazepines (odds ratio, 1.74; CI, 1-3.04), and mechanical ventilation (odds ratio, 0.43; CI, 0.2-0.8) were independently associated with gaps in memory. Non-ICU factor such as substance addiction (odds ratio, 5.38; CI, 2-14) was associated with memories affecting mental health and quality of life. CONCLUSIONS Gaps in memory and various memory types were common after ICU admission, whose prevalence waned over time. Compared with nightmares and fearful memories, gaps in memories were most strongly associated with poor mental health and quality of life. Identifying patients with gaps in memories might be an objective way of planning interventions to improve their long-term outcomes.
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Affiliation(s)
- Swagata Tripathy
- Department of Anesthesia and Critical Care, AIIMS Bhubaneswar, Odisha, India
- Department of Psychiatry, Black County Healthcare NHS Foundation Trust, Wolverhampton, United Kingdom
- Department of Psychiatry, AIIMS Bhubaneswar, Odisha, India
| | - Nilamadhab Kar
- Department of Psychiatry, Black County Healthcare NHS Foundation Trust, Wolverhampton, United Kingdom
| | | | - Santosh Kumar Singh
- Department of Psychiatry, Black County Healthcare NHS Foundation Trust, Wolverhampton, United Kingdom
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Abstract
OBJECTIVE To explore the experience of incontinence-associated dermatitis (IAD) as perceived by nurses, obstacles in the nursing process, and need for IAD training and management. METHODS This single-setting descriptive qualitative study was conducted from June 5, 2018, to June 22, 2018. Ten nurses working in the respiratory ICU of a local hospital participated in semistructured interviews. The content analysis method was used to analyze, summarize, and refine the interview data. RESULTS The experience of ICU nurses with IAD can be divided into four types: nursing based on experiential knowledge, seeking self-improvement, disunity of cleaning methods and wiping skills, and postponement of nursing care because of priority allocation. Obstacles in the nursing process include a lack of relevant nursing knowledge and awareness, as well as the medical supplies needed. The goals of training and management include establishing IAD preventive nursing procedures, providing IAD care products, enhancing the practicality of training content and diversifying training methods, and establishing an information system to assist nurses caring for patients with IAD. CONCLUSIONS The knowledge and behavior of ICU nurses regarding IAD need to be improved. Training and management are imperative. Facilities and nurse managers should actively seek solutions to stated obstacles, formulate training methods suitable for clinical needs, and promote the standardization of nursing for IAD.
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Affiliation(s)
- Yu Zhang
- At the Capital Medical University in Beijing, China, Yu Zhang, MSN, RN, is Nurse, Department of Respiratory and Critical Care Medicine; Peng Zhang, MSc, is Attending Doctor, Department of Urology, Beijing Chao-Yang Hospital; Jun-E Liu, MD, is Professor, School of Nursing; and Fengli Gao, MD, is Director, Nursing Department, Beijing Chao-Yang Hospital. Acknowledgment: The authors thank the Nursing Department of Beijing Chao-Yang Hospital for supporting this study, including the ICU nurses who agreed to share their experience and devote time and effort to this project. The authors have disclosed no financial relationships related to this article. Submitted September 24, 2020; accepted in revised form December 10, 2020
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18
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Al-Kawaz MN, Canner J, Caturegli G, Kannapadi N, Balucani C, Shelley L, Kim BS, Choi CW, Geocadin RG, Whitman G, Cho SM. Duration of Hyperoxia and Neurologic Outcomes in Patients Undergoing Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 49:e968-e977. [PMID: 33935164 DOI: 10.1097/ccm.0000000000005069] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the impact of duration of hyperoxia on neurologic outcome and mortality in patients undergoing venoarterial extracorporeal membrane oxygenation. DESIGN A retrospective analysis of venoarterial extracorporeal membrane oxygenation patients admitted to the Johns Hopkins Hospital. The primary outcome was neurologic function at discharge defined by modified Rankin Scale, with a score of 0-3 defined as a good neurologic outcome, and a score of 4-6 defined as a poor neurologic outcome. Multivariable logistic regression analysis was performed to evaluate the association between hyperoxia and neurologic outcomes. SETTING The Johns Hopkins Hospital Cardiovascular ICU and Cardiac Critical Care Unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We measured first and maximum Pao2 values, area under the curve per minute over the first 24 hours, and duration of mild, moderate, and severe hyperoxia. Of 132 patients on venoarterial extracorporeal membrane oxygenation, 127 (96.5%) were exposed to mild hyperoxia in the first 24 hours. Poor neurologic outcomes were observed in 105 patients (79.6%) (102 with vs 3 without hyperoxia; p = 0.14). Patients with poor neurologic outcomes had longer exposure to mild (19.1 vs 15.2 hr; p = 0.01), moderate (14.6 vs 9.2 hr; p = 0.003), and severe hyperoxia (9.1 vs 4.0 hr; p = 0.003). In a multivariable analysis, patients with worse neurologic outcome experienced longer durations of mild (adjusted odds ratio, 1.10; 95% CI, 1.01-1.19; p = 0.02), moderate (adjusted odds ratio, 1.12; 95% CI, 1.04-1.22; p = 0.002), and severe (adjusted odds ratio, 1.19; 95% CI, 1.06-1.35; p = 0.003) hyperoxia. Additionally, duration of severe hyperoxia was independently associated with inhospital mortality (adjusted odds ratio, 1.18; 95% CI, 1.08-1.29; p < 0.001). CONCLUSIONS In patients undergoing venoarterial extracorporeal membrane oxygenation, duration and severity of early hyperoxia were independently associated with poor neurologic outcomes at discharge and mortality.
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Affiliation(s)
- Mais N Al-Kawaz
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph Canner
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Giorgio Caturegli
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Nivedha Kannapadi
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Clotilde Balucani
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Leah Shelley
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chun Woo Choi
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Romergryko G Geocadin
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn Whitman
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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Chotalia M, Ali M, Alderman JE, Kalla M, Parekh D, Bangash MN, Patel JM. Right Ventricular Dysfunction and Its Association With Mortality in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome. Crit Care Med 2021; 49:1757-1768. [PMID: 34224453 PMCID: PMC8439642 DOI: 10.1097/ccm.0000000000005167] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess whether right ventricular dilation or systolic impairment is associated with mortality and/or disease severity in invasively ventilated patients with coronavirus disease 2019 acute respiratory distress syndrome. DESIGN Retrospective cohort study. SETTING Single-center U.K. ICU. PATIENTS Patients with coronavirus disease 2019 acute respiratory distress syndrome undergoing invasive mechanical ventilation that received a transthoracic echocardiogram between March and December 2020. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Right ventricular dilation was defined as right ventricular:left ventricular end-diastolic area greater than 0.6, right ventricular systolic impairment as fractional area change less than 35%, or tricuspid annular plane systolic excursion less than 17 mm. One hundred seventy-two patients were included, 59 years old (interquartile range, 49-67), with mostly moderate acute respiratory distress syndrome (n = 101; 59%). Ninety-day mortality was 41% (n = 70): 49% in patients with right ventricular dilation, 53% in right ventricular systolic impairment, and 72% in right ventricular dilation with systolic impairment. The right ventricular dilation with systolic impairment phenotype was independently associated with mortality (odds ratio, 3.11 [95% CI, 1.15-7.60]), but either disease state alone was not. Right ventricular fractional area change correlated with Pao2:Fio2 ratio, Paco2, chest radiograph opacification, and dynamic compliance, whereas right ventricular:left ventricle end-diastolic area correlated negatively with urine output. CONCLUSIONS Right ventricular systolic impairment correlated with pulmonary pathophysiology, whereas right ventricular dilation correlated with renal dysfunction. Right ventricular dilation with systolic impairment was the only right ventricular phenotype that was independently associated with mortality.
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Affiliation(s)
- Minesh Chotalia
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Muzzammil Ali
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Joseph E Alderman
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Manish Kalla
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Dhruv Parekh
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Mansoor N Bangash
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Jaimin M Patel
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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Affiliation(s)
- Rebecca A Aslakson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
- Division of Primary Care and Population Health, Department of Medicine, Palliative Care Section, Stanford University, Stanford, CA
| | - Christopher E Cox
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Judith G Baggs
- School of Nursing, Oregon Health & Science University, Portland, OR
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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Gonzenbach TP, McGuinness SP, Parke RL, Merz TM. Impact of Nonpharmaceutical Interventions on ICU Admissions During Lockdown for Coronavirus Disease 2019 in New Zealand-A Retrospective Cohort Study. Crit Care Med 2021; 49:1749-1756. [PMID: 34115636 PMCID: PMC8439630 DOI: 10.1097/ccm.0000000000005166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Nonpharmaceutical interventions are implemented internationally to mitigate the spread of severe acute respiratory syndrome coronavirus 2 with the aim to reduce coronavirus disease 2019-related deaths and to protect the health system, particularly intensive care facilities from being overwhelmed. The aim of this study is to describe the impact of nonpharmaceutical interventions on ICU admissions of non-coronavirus disease 2019-related patients. DESIGN Retrospective cohort study. SETTING Analysis of all reported adult patient admissions to New Zealand ICUs during Level 3 and Level 4 lockdown restrictions from March 23, to May 13, 2020, in comparison with equivalent periods from 5 previous years (2015-2019). SUBJECTS Twelve-thousand one-hundred ninety-two ICU admissions during the time periods of interest were identified. MEASUREMENTS Patient data were obtained from the Australian and New Zealand Intensive Care Society Adult Patient Database, Australian and New Zealand Intensive Care Society critical care resources registry, and Statistics New Zealand. Study variables included patient baseline characteristics and ICU resource use. MAIN RESULTS Nonpharmaceutical interventions in New Zealand were associated with a 39.1% decrease in ICU admission rates (p < 0.0001). Both elective (-44.2%) and acute (-36.5%) ICU admissions were significantly reduced when compared with the average of the previous 5 years (both p < 0.0001). ICU occupancy decreased from a mean of 64.3% (2015-2019) to 39.8% in 2020. Case mix, ICU resource use per patient, and ICU and hospital mortality remained unchanged. CONCLUSIONS The institution of nonpharmaceutical interventions was associated with a significant decrease in elective and acute ICU admissions and ICU resource use. These findings may help hospitals and health authorities planning for surge capacities and elective surgery management in future pandemics.
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Affiliation(s)
- Tobias P Gonzenbach
- Cardiothoracic and Vascular ICU (CVICU), Auckland City Hospital, Auckland, New Zealand
| | - Shay P McGuinness
- Cardiothoracic and Vascular ICU (CVICU), Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- ANZIC-Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Rachael L Parke
- Cardiothoracic and Vascular ICU (CVICU), Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- ANZIC-Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Tobias M Merz
- Cardiothoracic and Vascular ICU (CVICU), Auckland City Hospital, Auckland, New Zealand
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22
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Chemali M, Laurent A, Scaletta C, Waselle L, Simon JP, Michetti M, Brunet JF, Flahaut M, Hirt-Burri N, Raffoul W, Applegate LA, de Buys Roessingh AS, Abdel-Sayed P. Burn Center Organization and Cellular Therapy Integration: Managing Risks and Costs. J Burn Care Res 2021; 42:911-924. [PMID: 33970273 PMCID: PMC8483250 DOI: 10.1093/jbcr/irab080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The complex management of severe burn victims requires an integrative collaboration of multidisciplinary specialists in order to ensure quality and excellence in healthcare. This multidisciplinary care has quickly led to the integration of cell therapies in clinical care of burn patients. Specific advances in cellular therapy together with medical care have allowed for rapid treatment, shorter residence in hospitals and intensive care units, shorter durations of mechanical ventilation, lower complications and surgery interventions, and decreasing mortality rates. However, naturally fluctuating patient admission rates increase pressure toward optimized resource utilization. Besides, European translational developments of cellular therapies currently face potentially jeopardizing challenges on the policy front. The aim of the present work is to provide key considerations in burn care with focus on architectural and organizational aspects of burn centers, management of cellular therapy products, and guidelines in evolving restrictive regulations relative to standardized cell therapies. Thus, based on our experience, we present herein integrated management of risks and costs for preserving and optimizing clinical care and cellular therapies for patients in dire need.
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Affiliation(s)
- Michèle Chemali
- Department of Musculoskeletal Medicine, Plastic, Reconstructive and Hand Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
- Department of Interdisciplinary Centers, Lausanne Burn Center, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Alexis Laurent
- Department of Musculoskeletal Medicine, Plastic, Reconstructive and Hand Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Corinne Scaletta
- Department of Musculoskeletal Medicine, Plastic, Reconstructive and Hand Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Laurent Waselle
- Department of Interdisciplinary Centers, Cell Production Center, Service of Pharmacy, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Jeanne-Pascale Simon
- DIrectorate Department, Unit of Legal Affairs, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Murielle Michetti
- Department of Musculoskeletal Medicine, Plastic, Reconstructive and Hand Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Jean-François Brunet
- Department of Interdisciplinary Centers, Cell Production Center, Service of Pharmacy, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Marjorie Flahaut
- Department of Musculoskeletal Medicine, Plastic, Reconstructive and Hand Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Nathalie Hirt-Burri
- Department of Musculoskeletal Medicine, Plastic, Reconstructive and Hand Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Wassim Raffoul
- Department of Musculoskeletal Medicine, Plastic, Reconstructive and Hand Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
- Department of Interdisciplinary Centers, Lausanne Burn Center, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Lee Ann Applegate
- Department of Musculoskeletal Medicine, Plastic, Reconstructive and Hand Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
- Department of Interdisciplinary Centers, Lausanne Burn Center, Lausanne University Hospital, University of Lausanne, Switzerland
- Oxford Suzhou Center for Advanced Research, Science and Technology Co. Ltd., Oxford University, Suzhou, PR China
- Center for Applied Biotechnology and Molecular Medicine, University of Zurich, Switzerland
| | - Anthony S de Buys Roessingh
- Department of Interdisciplinary Centers, Lausanne Burn Center, Lausanne University Hospital, University of Lausanne, Switzerland
- Women-Mother-Child Department, Children and Adolescent Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Philippe Abdel-Sayed
- Department of Musculoskeletal Medicine, Plastic, Reconstructive and Hand Surgery Service, Lausanne University Hospital, University of Lausanne, Switzerland
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Yang S, Zhao H, Wang H, Zhang H, An Y. Comparison between remifentanil and other opioids in adult critically ill patients: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27275. [PMID: 34559131 PMCID: PMC8462581 DOI: 10.1097/md.0000000000027275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 08/15/2021] [Accepted: 08/31/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND AIMS To identify the efficacy and safety of remifentanil when compared with other opioids in adult critically ill patients. METHODS We searched for studies in the Cochrane Library, MEDLINE, and EMBASE that had been published up to May 31st, 2019. Randomized clinical trials using remifentanil comparing with other opioids for analgesia were included. Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. Duration of mechanical ventilation was the primary outcome, and secondary outcomes included weaning time, intensive care unit (ICU), length of stay (LOS), hospital LOS, mortality, side effects, and costs. RESULTS Fifteen studies with 1233 patients were included. Remifentanil was associated with a significant reduction in the duration of mechanical ventilation in the adult ICU patients when compared with other opioids (P = .01). Remifentanil also reduced the weaning time (P = .02) and the ICU LOS when compared with other opioids (P = .01). There was no difference in the hospital LOS (P = .15), side effects (P = .39), and mortality (P = .79) between remifentanil and other opioids, what's more, remifentanil increased the costs of anesthesia (P < .001) but did not increase cost of hospitalization (P = .30) when comparing with other opioids. CONCLUSIONS Remifentanil reduced the duration of mechanical ventilation, weaning time, and ICU LOS when compared with other opioids in adult critically ill patients. Higher quality RCTs are necessary to prove our findings. PROSPERO REGISTRATION NUMBER CRD42016041438.
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Affiliation(s)
- Shuguang Yang
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Huixia Wang
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Hua Zhang
- Epidemiology Center, Peking University Third Hospital, Beijing, China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
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24
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Guirgis FW, Black LP, Henson M, Labilloy G, Smotherman C, Hopson C, Tfirn I, DeVos EL, Leeuwenburgh C, Moldawer L, Datta S, Brusko TM, Hester A, Bertrand A, Grijalva V, Arango-Esterhay A, Moore FA, Reddy ST. A hypolipoprotein sepsis phenotype indicates reduced lipoprotein antioxidant capacity, increased endothelial dysfunction and organ failure, and worse clinical outcomes. Crit Care 2021; 25:341. [PMID: 34535154 PMCID: PMC8447561 DOI: 10.1186/s13054-021-03757-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 09/01/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Approximately one-third of sepsis patients experience poor outcomes including chronic critical illness (CCI, intensive care unit (ICU) stay > 14 days) or early death (in-hospital death within 14 days). We sought to characterize lipoprotein predictive ability for poor outcomes and contribution to sepsis heterogeneity. DESIGN Prospective cohort study with independent replication cohort. SETTING Emergency department and surgical ICU at two hospitals. PATIENTS Sepsis patients presenting within 24 h. METHODS Measures included cholesterol levels (total cholesterol, high density lipoprotein cholesterol [HDL-C], low density lipoprotein cholesterol [LDL-C]), triglycerides, paraoxonase-1 (PON-1), and apolipoprotein A-I (Apo A-I) in the first 24 h. Inflammatory and endothelial markers, and sequential organ failure assessment (SOFA) scores were also measured. LASSO selection assessed predictive ability for outcomes. Unsupervised clustering was used to investigate the contribution of lipid variation to sepsis heterogeneity. MEASUREMENTS AND MAIN RESULTS 172 patients were enrolled. Most (~ 67%, 114/172) rapidly recovered, while ~ 23% (41/172) developed CCI, and ~ 10% (17/172) had early death. ApoA-I, LDL-C, mechanical ventilation, vasopressor use, and Charlson Comorbidity Score were significant predictors of CCI/early death in LASSO models. Unsupervised clustering yielded two discernible phenotypes. The Hypolipoprotein phenotype was characterized by lower lipoprotein levels, increased endothelial dysfunction (ICAM-1), higher SOFA scores, and worse clinical outcomes (45% rapid recovery, 40% CCI, 16% early death; 28-day mortality, 21%). The Normolipoprotein cluster patients had higher cholesterol levels, less endothelial dysfunction, lower SOFA scores and better outcomes (79% rapid recovery, 15% CCI, 6% early death; 28-day mortality, 15%). Phenotypes were validated in an independent replication cohort (N = 86) with greater sepsis severity, which similarly demonstrated lower HDL-C, ApoA-I, and higher ICAM-1 in the Hypolipoprotein cluster and worse outcomes (46% rapid recovery, 23% CCI, 31% early death; 28-day mortality, 42%). Normolipoprotein patients in the replication cohort had better outcomes (55% rapid recovery, 32% CCI, 13% early death; 28-day mortality, 28%) Top features for cluster discrimination were HDL-C, ApoA-I, total SOFA score, total cholesterol level, and ICAM-1. CONCLUSIONS Lipoproteins predicted poor sepsis outcomes. A Hypolipoprotein sepsis phenotype was identified and characterized by lower lipoprotein levels, increased endothelial dysfunction (ICAM-1) and organ failure, and worse clinical outcomes.
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Affiliation(s)
- Faheem W Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA.
| | - Lauren Page Black
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Morgan Henson
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Guillaume Labilloy
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Carmen Smotherman
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Charlotte Hopson
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Ian Tfirn
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Elizabeth L DeVos
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Christiaan Leeuwenburgh
- Department of Aging and Geriatric Research, University of Florida College of Medicine, Gainesville, FL, USA
| | - Lyle Moldawer
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Susmita Datta
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Todd M Brusko
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida Diabetes Institute, College of Medicine, Gainesville, FL, USA
- Department of Pediatrics, University of Florida Diabetes Institute, College of Medicine, Gainesville, FL, USA
| | - Alexis Hester
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Andrew Bertrand
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Victor Grijalva
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alexander Arango-Esterhay
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Frederick A Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Srinivasa T Reddy
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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25
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Chabert P, Danjou W, Mezidi M, Berthiller J, Bestion A, Fred AA, Guerin C, Argaud L, Piriou V, Bonnefoy-Cudraz E, Lehot JJ, Fellahi JL, Rimmele T, Aubrun F, Richard JC, Gallay L, Hot A. Short- and long-term prognosis of acute critically ill patients with systemic rheumatic diseases: A retrospective multicentre study. Medicine (Baltimore) 2021; 100:e26164. [PMID: 34477112 PMCID: PMC8415942 DOI: 10.1097/md.0000000000026164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/06/2021] [Indexed: 01/05/2023] Open
Abstract
Patients with systemic rheumatic disease (SRD) share the risks of multi-organ flare-up, cardiovascular diseases, and immunosuppression. Such situations can lead to an acute critical illness. The present study describes the clinical features of SRD patients admitted to the intensive care unit (ICU) and their short- and long- term mortality.We performed a multicentre retrospective study in 10 French ICU in Lyon, France. Inclusion criteria were SRD diagnosis and admission for an acute organ failure. The primary endpoint was ICU mortality.A total of 271 patients were included. SRD included systemic lupus erythematosus (23.2% of included patients), vasculitis (10.7%), systemic sclerosis (10.7%), idiopathic inflammatory myopathy (6.3%), and other connective tissue disorders (rheumatoid arthritis, Sjögren and Sharp syndromes; 50.9%). Initial organ failure(s) were shock (43.5% of included patients), acute kidney injury (30.5%), and acute respiratory failure (23.2%). The cause(s) of ICU admission included sepsis (61.6%), cardiovascular events (33.9%), SRD-flare up (32.8%), and decompensations related to comorbidities (28%). The ICU mortality reached 14.3%. The factors associated with ICU mortality were chronic cardiac failure, invasive ventilation and admission in ICU for another reason than sepsis or SRD flare-up. The median follow-up after ICU discharge was 33.6 months. During follow-up, 109 patients died. The factors associated with long-term mortality included age, Charlson comorbidity index, and ICU admission for sepsis or SRD flare-up.The ICU mortality of patients with SRD was low. Sepsis was the first cause of admission. Cardiovascular events and comorbidities negatively impacted ICU mortality. Admission for sepsis or SRD flare-up exerted a negative effect on the long-term outcome.
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Affiliation(s)
- Paul Chabert
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Lyon, France
| | - William Danjou
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Lyon, France
| | - Mehdi Mezidi
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Lyon, France
| | | | - Audrey Bestion
- Hospices Civils de Lyon, Département Information Médicale, France
| | - Abla-Akpene Fred
- Hospices Civils de Lyon, Département Information Médicale, France
| | - Claude Guerin
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Lyon, France
- Université de Lyon, France
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital Edouard Herriot, Lyon, France
- Institut Mondor de Recherche Biomédicale INSERM 955, ERL CNRS, 7000 Créteil, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital Edouard Herriot, Lyon, France
| | - Vincent Piriou
- Université de Lyon, France
- Hospices Civils de Lyon, Anesthésie-Réanimation-Médecine Intensive, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Eric Bonnefoy-Cudraz
- Hospices Civils de Lyon, Service d’urgences cardiologiques et de soins intensifs de cardiologie, Hôpital Louis Pradel, Bron, France
| | - Jean-Jacques Lehot
- Hospices Civils de Lyon, Anesthésie-Réanimation Neurologique, Hôpital Pierre Wertheimer, Bron, France
| | - Jean-Luc Fellahi
- Hospices Civils de Lyon, Anesthésie-Réanimation cardio-thoracique et vasculaire, Hôpital Louis Pradel, Bron, France
| | - Thomas Rimmele
- Hospices Civils de Lyon, Anesthésie-Réanimation, Hôpital Edouard Herriot, Lyon, France
| | - Frederic Aubrun
- Hospices Civils de Lyon, Anesthésie-Réanimation, Hôpital de la croix rousse, Lyon, France
| | - Jean-Christophe Richard
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Lyon, France
- Université de Lyon, France
| | - Laure Gallay
- Université de Lyon, France
- Hospices Civils de Lyon, Médecine Interne, Hôpital Edouard Herriot, Lyon, France
| | - Arnaud Hot
- Université de Lyon, France
- Hospices Civils de Lyon, Médecine Interne, Hôpital Edouard Herriot, Lyon, France
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26
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Corcione S, Lupia T, Raviolo S, Montrucchio G, Trentalange A, Curtoni A, Cavallo R, De Rosa FG. Putative invasive pulmonary aspergillosis within medical wards and intensive care units: a 4-year retrospective, observational, single-centre study. Intern Emerg Med 2021; 16:1619-1627. [PMID: 33751395 PMCID: PMC8354984 DOI: 10.1007/s11739-021-02705-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 03/08/2021] [Indexed: 12/14/2022]
Abstract
Blot and colleagues have proposed putative invasive pulmonary aspergillosis (PIPA) definitions for troublesome diagnosis in suspected patients outside the classical criteria of immunosuppression. We retrospectively included in the study all admitted patients with an Aspergillus spp. positive culture within lower airway samples. Overall, Aspergillus spp. positivity in respiratory samples was 0.97 every 1000 hospital admissions (HA): 4.94 and 0.28/1000/HA, respectively, in intensive care units (ICUs) and medical wards (MW). 66.6% fulfilled PIPA criteria, and 33.4% were defined as colonized. 69.2% of PIPA diagnosis occurred in the ICU. Antifungal therapy was appropriate in 88.5% of subjects with PIPA and 37.5% of colonized, confirming the comparison between deads and lives. Patients with PIPA in the ICUs had more frequent COPD, sepsis or septic shock, acute kidney injury (AKI), needed more surgery, mechanical ventilation (MV), vasopressors, hemodialysis, blood or platelets transfusions. PIPA in MW had associated with a history of smoking, interstitial lung disease and inhaled steroid therapy. Overall mortality within 21 days was 50%: 54.2% in ICU, 36,8% in MW. Factors associated with death were length of hospitalization, influenza, pneumonia, liver transplant, AKI, ARDS, sepsis and septic shock. PIPA in the ICU had higher disease severity and needed more organ support than MW cases, despite that cases of PIPA in MW are emerging with trends difficult to demonstrate given the problematic diagnosis.
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Affiliation(s)
- Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
- Tufts University School of Medicine, Boston, USA
| | - Tommaso Lupia
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy.
| | - Stefania Raviolo
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Giorgia Montrucchio
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Alice Trentalange
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Antonio Curtoni
- Microbiology and Virology Unit, University of Turin, Turin, Italy
| | - Rossana Cavallo
- Microbiology and Virology Unit, University of Turin, Turin, Italy
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27
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Skrifvars MB, Sekhon M, Åneman EA. Monitoring and modifying brain oxygenation in patients at risk of hypoxic ischaemic brain injury after cardiac arrest. Crit Care 2021; 25:312. [PMID: 34461973 PMCID: PMC8406909 DOI: 10.1186/s13054-021-03678-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Markus Benedikt Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Erik Anders Åneman
- Southwestern Clinical School, University of New South Wales, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- College of Health and Medicine, Australian National University, Canberra, NSW, Australia
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Liverpool, NSW, Australia
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28
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Kosuke Yagi
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Tomoko Fujii
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan.
- ANZIC-RC, Monash University School of Public Health and Preventive Medicine, Melbourne, VIC, Australia.
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Tatiana Weinstein
- Department of Pulmonary and Critical Care, New York University School of Medicine, New York, NY, USA
| | - Himanshu Deshwal
- Department of Pulmonary and Critical Care, New York University School of Medicine, New York, NY, USA
| | - Shari B Brosnahan
- Department of Pulmonary and Critical Care, New York University School of Medicine, New York, NY, USA.
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CibeRes), Madrid, Spain.
| | - Andrés Pacheco
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marina García-de-Acilu
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Departament de Medicina, Universitat Autònma de Barcelona, Bellatera, Spain
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Kieninger M, Mandlinger A, Doblinger N, Kieninger B, Bele S, Salzberger B, Schneider-Brachert W, Graf B, Zeman F, Holzmann T. Impact of the implementation of a standard for preanalytical handling of samples for microbiological diagnostics on the quality of results at a neurocritical care unit. Medicine (Baltimore) 2021; 100:e27060. [PMID: 34449497 PMCID: PMC10545238 DOI: 10.1097/md.0000000000027060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 07/29/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Antibiotic stewardship (ABS) programs intend to improve outcomes of nosocomial infections and to counteract the emergence of further antimicrobial resistances. At the anesthesiologic-neurosurgical intensive care unit (ICU) of the University Medical Center Regensburg (Germany) we implemented a standard operating procedure (SOP) with clear instructions for the preanalytical handling and storage of microbiological samples. We intended to find out whether the instructions given in the SOP led to a higher rate of ideal material being sent to the laboratory and to overall better quality of the received results.We retraced retrospectively all samples taken in cases of suspected pneumonia, urinary tract infection, bloodstream infection, catheter infection associated with a central venous or arterial catheter and ventriculitis due to external ventricular drainage as well as all smears taken for the screening for multi-resistant bacteria within a time period of 1 year before to 1 year after the implementation of the SOP.In the case of suspected pneumonia and urinary tract infection, large amounts of ideal material were sent to the microbiological laboratory. A remarkable improvement after the implementation of the SOP, however, could only be observed regarding the number of urine samples taken from older urinary catheters, which was significantly lower in the "SOP group". Samples for microbiological diagnostics were taken much more often in the daytime, although storage of the probes did not lead to worse results.Concrete instructions enable adequate preanalytical handling of microbiological probes. However, we could not recognize substantial improvements probably due to a preexisting high process quality on the ICU. Microbiological diagnostics during the night shift has to be improved.
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Affiliation(s)
- Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Germany
| | - Andreas Mandlinger
- Department of Anesthesiology, University Medical Center Regensburg, Germany
| | - Nina Doblinger
- Department of Anesthesiology, University Medical Center Regensburg, Germany
| | - Bärbel Kieninger
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Germany
| | - Sylvia Bele
- Department of Neurosurgery, University Medical Center Regensburg, Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Germany
| | - Wulf Schneider-Brachert
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Germany
| | - Bernhard Graf
- Department of Anesthesiology, University Medical Center Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Germany
| | - Thomas Holzmann
- Department of Infection Prevention and Infectious Diseases, University Medical Center Regensburg, Germany
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Catho G, Martischang R, Boroli F, Chraïti MN, Martin Y, Koyluk Tomsuk Z, Renzi G, Schrenzel J, Pugin J, Nordmann P, Blanc DS, Harbarth S. Outbreak of Pseudomonas aeruginosa producing VIM carbapenemase in an intensive care unit and its termination by implementation of waterless patient care. Crit Care 2021; 25:301. [PMID: 34412676 PMCID: PMC8376114 DOI: 10.1186/s13054-021-03726-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/09/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Long-term outbreaks of multidrug-resistant Gram-negative bacilli related to hospital-building water systems have been described. However, successful mitigation strategies have rarely been reported. In particular, environmental disinfection or replacement of contaminated equipment usually failed to eradicate environmental sources of Pseudomonas aeruginosa. METHODS We report the investigation and termination of an outbreak of P. aeruginosa producing VIM carbapenemase (PA-VIM) in the adult intensive care unit (ICU) of a Swiss tertiary care hospital with active case finding, environmental sampling and whole genome sequencing (WGS) of patient and environmental strains. We also describe the implemented control strategies and their effectiveness on eradication of the environmental reservoir. RESULTS Between April 2018 and September 2020, 21 patients became either infected or colonized with a PA-VIM strain. For 16 of them, an acquisition in the ICU was suspected. Among 131 environmental samples collected in the ICU, 13 grew PA-VIM in sink traps and drains. WGS confirmed the epidemiological link between clinical and environmental strains and the monoclonal pattern of the outbreak. After removing sinks from patient rooms and implementation of waterless patient care, no new acquisition was detected in the ICU within 8 months after the intervention. DISCUSSION Implementation of waterless patient care with removal of the sinks in patient rooms was successful for termination of a PA-VIM ICU outbreak linked to multiple environmental water sources. WGS provides highly discriminatory accuracy to investigate environment-related outbreaks.
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Affiliation(s)
- Gaud Catho
- Infection Control Program, WHO Collaborating Center for Patient Safety, Faculty of Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil, 4, CH-1205, Geneva, Switzerland.
| | - R Martischang
- Infection Control Program, WHO Collaborating Center for Patient Safety, Faculty of Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil, 4, CH-1205, Geneva, Switzerland
| | - F Boroli
- Division of Critical Care, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - M N Chraïti
- Infection Control Program, WHO Collaborating Center for Patient Safety, Faculty of Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil, 4, CH-1205, Geneva, Switzerland
| | - Y Martin
- Infection Control Program, WHO Collaborating Center for Patient Safety, Faculty of Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil, 4, CH-1205, Geneva, Switzerland
| | - Z Koyluk Tomsuk
- Division of Critical Care, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - G Renzi
- Bacteriology Laboratory, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - J Schrenzel
- Bacteriology Laboratory, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - J Pugin
- Division of Critical Care, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - P Nordmann
- Emerging Antibiotic Resistance Unit, Medical and Molecular Microbiology, Department of Medicine, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Swiss National Reference Center for Emerging Antibiotic Resistance, Fribourg, Switzerland
| | - D S Blanc
- Swiss National Reference Center for Emerging Antibiotic Resistance, Fribourg, Switzerland
- Service of Hospital Preventive Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - S Harbarth
- Infection Control Program, WHO Collaborating Center for Patient Safety, Faculty of Medicine, Geneva University Hospitals, Rue Gabrielle Perret-Gentil, 4, CH-1205, Geneva, Switzerland
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Flannery AH, Ortiz-Soriano V, Li X, Gianella FG, Toto RD, Moe OW, Devarajan P, Goldstein SL, Neyra JA. Serum renin and major adverse kidney events in critically ill patients: a multicenter prospective study. Crit Care 2021; 25:294. [PMID: 34391450 PMCID: PMC8364694 DOI: 10.1186/s13054-021-03725-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/04/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Preliminary studies have suggested that the renin-angiotensin system is activated in critical illness and associated with mortality and kidney outcomes. We sought to assess in a larger, multicenter study the relationship between serum renin and Major Adverse Kidney Events (MAKE) in intensive care unit (ICU) patients. METHODS Prospective, multicenter study at two institutions of patients with and without acute kidney injury (AKI). Blood samples were collected for renin measurement a median of 2 days into the index ICU admission and 5-7 days later. The primary outcome was MAKE at hospital discharge, a composite of mortality, kidney replacement therapy, or reduced estimated glomerular filtration rate to ≤ 75% of baseline. RESULTS Patients in the highest renin tertile were more severely ill overall, including more AKI, vasopressor-dependence, and severity of illness. MAKE were significantly greater in the highest renin tertile compared to the first and second tertiles. In multivariable logistic regression, this initial measurement of renin remained significantly associated with both MAKE as well as the individual component of mortality. The association of renin with MAKE in survivors was not statistically significant. Renin measurements at the second time point were also higher in patients with MAKE. The trajectory of the renin measurements between time 1 and 2 was distinct when comparing death versus survival, but not when comparing MAKE versus those without. CONCLUSIONS In a broad cohort of critically ill patients, serum renin measured early in the ICU admission is associated with MAKE at discharge, particularly mortality.
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Affiliation(s)
- Alexander H Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Victor Ortiz-Soriano
- Department of Internal Medicine, Division of Nephrology, Bone, and Mineral Metabolism, University of Kentucky College of Medicine, Lexington, KY, 40536, USA
| | - Xilong Li
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fabiola G Gianella
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert D Toto
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone, and Mineral Metabolism, University of Kentucky College of Medicine, Lexington, KY, 40536, USA.
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Affiliation(s)
- David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Kingston Health Sciences Centre, Kingston, ON, Canada
- Roslin Institute, University of Edinburgh, Easter Bush, Edinburgh, United Kingdom
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, United Kingdom
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - J Kenneth Baillie
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Kingston Health Sciences Centre, Kingston, ON, Canada
- Roslin Institute, University of Edinburgh, Easter Bush, Edinburgh, United Kingdom
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, United Kingdom
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Violi F, Ceccarelli G, Cangemi R, Cipollone F, D'Ardes D, Oliva A, Pirro M, Rocco M, Alessandri F, D'Ettorre G, Lichtner M, Pignatelli P, Ferro D, Ruberto F, Lip GYH, Pugliese F, Mastroianni CM. Arterial and venous thrombosis in coronavirus 2019 disease (Covid-19): relationship with mortality. Intern Emerg Med 2021; 16:1231-1237. [PMID: 34218413 PMCID: PMC8255055 DOI: 10.1007/s11739-020-02621-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients with coronavirus disease 2019 (Covid-19) may experience venous thrombosis while data regarding arterial thrombosis are sparse. METHODS Prospective multicenter study in 5 hospitals including 373 patients with Covid-19-related pneumonia. Demographic data, laboratory findings including coagulation tests and comorbidities were reported. During the follow-up any arterial or venous thrombotic events and death were registered. RESULTS Among 373 patients, 75 (20%) had a thrombotic event and 75 (20%) died. Thrombotic events included 41 venous thromboembolism and 34 arterial thrombosis. Age, cardiovascular disease, intensive care unit treatment, white blood cells, D-dimer, albumin and troponin blood levels were associated with thrombotic events. In a multivariable regression logistic model, intensive care unit treatment (Odds Ratio [OR]: 6.0; 95% Confidence Interval [CI] 2.8-12.6; p < 0.001); coronary artery disease (OR: 2.4; 95% CI 1.4-5.0; p = 0.022); and albumin levels (OR: 0.49; 95% CI 0.28-0.87; p = 0.014) were associated with ischemic events. Age, sex, chronic obstructive pulmonary disease, diabetes, heart failure, coronary heart disease, intensive care unit treatment, in-hospital thrombotic events, D-dimer, C-reactive protein, troponin, and albumin levels were associated with mortality. A multivariable Cox regression analysis showed that in-hospital thrombotic events (hazard ratio [HR]: 2.72; 95% CI 1.59-4.65; p < 0.001), age (HR: 1.035; 95% CI 1.014-1.057; p = 0.001), and albumin (HR: 0.447; 95% CI 0.277-0.723; p = 0.001) predicted morality. CONCLUSIONS Covid-19 patients experience an equipollent rate of venous and arterial thrombotic events, that are associated with poor survival. Early identification and appropriate treatment of Covid-19 patients at risk of thrombosis may improve prognosis.
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Affiliation(s)
- Francesco Violi
- I Clinica Medica, Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Roma, Italy.
- Mediterranea Cardiocentro, Naples, Italy.
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Roberto Cangemi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Cipollone
- Clinica Medica, Department of Medicine and Aging, "G. D'Annunzio, University of Chieti-Pescara, Chieti, Italy
| | - Damiano D'Ardes
- Clinica Medica, Department of Medicine and Aging, "G. D'Annunzio, University of Chieti-Pescara, Chieti, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Matteo Pirro
- Unit of Internal Medicine, Department of Medicine, University of Perugia, Perugia, Italy
| | - Monica Rocco
- Dipartimento Emergenza E Accettazione, Ospedale Universitario Sant'Andrea, Rome, Italy
| | - Francesco Alessandri
- Department of General Surgery Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | - Gabriella D'Ettorre
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Miriam Lichtner
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Roma, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Domenico Ferro
- I Clinica Medica, Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Roma, Italy
| | - Franco Ruberto
- Department of General Surgery Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francesco Pugliese
- Department of General Surgery Paride Stefanini, Sapienza University of Rome, Rome, Italy
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Ma P, Liu J, Shen F, Liao X, Xiu M, Zhao H, Zhao M, Xie J, Wang P, Huang M, Li T, Duan M, Qian K, Peng Y, Zhou F, Xin X, Wan X, Wang Z, Li S, Han J, Li Z, Ding G, Deng Q, Zhang J, Zhu Y, Ma W, Wang J, Kang Y, Zhang Z. Individualized resuscitation strategy for septic shock formalized by finite mixture modeling and dynamic treatment regimen. Crit Care 2021; 25:243. [PMID: 34253228 PMCID: PMC8273991 DOI: 10.1186/s13054-021-03682-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/06/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Septic shock comprises a heterogeneous population, and individualized resuscitation strategy is of vital importance. The study aimed to identify subclasses of septic shock with non-supervised learning algorithms, so as to tailor resuscitation strategy for each class. METHODS Patients with septic shock in 25 tertiary care teaching hospitals in China from January 2016 to December 2017 were enrolled in the study. Clinical and laboratory variables were collected on days 0, 1, 2, 3 and 7 after ICU admission. Subclasses of septic shock were identified by both finite mixture modeling and K-means clustering. Individualized fluid volume and norepinephrine dose were estimated using dynamic treatment regime (DTR) model to optimize the final mortality outcome. DTR models were validated in the eICU Collaborative Research Database (eICU-CRD) dataset. RESULTS A total of 1437 patients with a mortality rate of 29% were included for analysis. The finite mixture modeling and K-means clustering robustly identified five classes of septic shock. Class 1 (baseline class) accounted for the majority of patients over all days; class 2 (critical class) had the highest severity of illness; class 3 (renal dysfunction) was characterized by renal dysfunction; class 4 (respiratory failure class) was characterized by respiratory failure; and class 5 (mild class) was characterized by the lowest mortality rate (21%). The optimal fluid infusion followed the resuscitation/de-resuscitation phases with initial large volume infusion and late restricted volume infusion. While class 1 transitioned to de-resuscitation phase on day 3, class 3 transitioned on day 1. Classes 1 and 3 might benefit from early use of norepinephrine, and class 2 can benefit from delayed use of norepinephrine while waiting for adequate fluid infusion. CONCLUSIONS Septic shock comprises a heterogeneous population that can be robustly classified into five phenotypes. These classes can be easily identified with routine clinical variables and can help to tailor resuscitation strategy in the context of precise medicine.
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Affiliation(s)
- Penglin Ma
- Department of Critical Care Medicine, Guiqian International General Hospital, Guiyang, People's Republic of China
| | - Jingtao Liu
- Department of Critical Care Medicine, The 8th Medical Center of Chinese, PLA General Hospital, Beijing, 100091, People's Republic of China
| | - Feng Shen
- Department of Intensive Care Unit, Guizhou Medical University Affiliated Hospital, Guiyang, People's Republic of China
| | - Xuelian Liao
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Ming Xiu
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, People's Republic of China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei General Hospital, Shijiazhuang, People's Republic of China
| | - Mingyan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Jing Xie
- General Intensive Care Unit Department, The First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Peng Wang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Man Huang
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University, Hangzhou, People's Republic of China
| | - Tong Li
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Meili Duan
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Kejian Qian
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Yue Peng
- Department of Critical Care Medicine, The Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Feihu Zhou
- Department of Critical Care Medicine, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Xin Xin
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xianyao Wan
- The First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China
| | - ZongYu Wang
- Department of Intensive Care, Peking University Third Hospital, Beijing, People's Republic of China
| | - Shusheng Li
- Department of Emergency, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jianwei Han
- Department of Critical Care Medicine, The 8th medical Center of Chinese, PLA General Hospital, Beijing, People's Republic of China
| | - Zhenliang Li
- Department of Critical Care, Beijing PingGu Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Guolei Ding
- Intensive Care Unit, The Hospital of Shunyi District, Beijing, People's Republic of China
| | - Qun Deng
- Department of Critical Care Medicine, The 4th Medical Center of Chinese, PLA General Hospital, Beijing, People's Republic of China
| | - Jicheng Zhang
- Department of Critical Care Medicine, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, Jinan, People's Republic of China
| | - Yue Zhu
- Department of Critical Care, Beijing Luhe Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wenjing Ma
- Department of Critical Care, Beijing Miyun Hospital, Beijing, People's Republic of China
| | - Jingwen Wang
- Intensive Care Unit, Beijing Changping District Hospital, Beijing, People's Republic of China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, People's Republic of China.
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Mathews KS, Seitz KP, Vranas KC, Duggal A, Valley TS, Zhao B, Gundel S, Harhay MO, Chang SY, Hough CL. Variation in Initial U.S. Hospital Responses to the Coronavirus Disease 2019 Pandemic. Crit Care Med 2021; 49:1038-1048. [PMID: 33826584 PMCID: PMC8217146 DOI: 10.1097/ccm.0000000000005013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The coronavirus disease 2019 pandemic has strained many healthcare systems. In response, U.S. hospitals altered their care delivery systems, but there are few data regarding specific structural changes. Understanding these changes is important to guide interpretation of outcomes and inform pandemic preparedness. We sought to characterize emergency responses across hospitals in the United States over time and in the context of local case rates early in the coronavirus disease 2019 pandemic. DESIGN We surveyed hospitals from a national acute care trials group regarding operational and structural changes made in response to the coronavirus disease 2019 pandemic from January to August 2020. We collected prepandemic characteristics and changes to hospital system, space, staffing, and equipment during the pandemic. We compared the timing of these changes with county-level coronavirus disease 2019 case rates. SETTING AND PARTICIPANTS U.S. hospitals participating in the Prevention and Early Treatment of Acute Lung Injury Network Coronavirus Disease 2019 Observational study. Site investigators at each hospital collected local data. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty-five sites participated (94% response rate). System-level changes (incident command activation and elective procedure cancellation) occurred at nearly all sites, preceding rises in local case rates. The peak inpatient census during the pandemic was greater than the prior hospital bed capacity in 57% of sites with notable regional variation. Nearly half (49%) expanded ward capacity, and 63% expanded ICU capacity, with nearly all bed expansion achieved through repurposing of clinical spaces. Two-thirds of sites adapted staffing to care for patients with coronavirus disease 2019, with 48% implementing tiered staffing models, 49% adding temporary physicians, nurses, or respiratory therapists, and 30% changing the ratios of physicians or nurses to patients. CONCLUSIONS The coronavirus disease 2019 pandemic prompted widespread system-level changes, but front-line clinical care varied widely according to specific hospital needs and infrastructure. Linking operational changes to care delivery processes is a necessary step to understand the impact of the coronavirus disease 2019 pandemic on patient outcomes.
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Affiliation(s)
- Kusum S. Mathews
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kevin P. Seitz
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee
| | - Kelly C. Vranas
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care , Oregon Health & Science University, Portland, Oregon
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Thomas S. Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan
| | - Bo Zhao
- Department of Geography, University of Washington, Seattle, Washington
| | - Stephanie Gundel
- Department of Medicine, University of Washington, Seattle, Washington
| | - Michael O. Harhay
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven Y. Chang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan-UCLA Medical Center, Los Angeles, California
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care , Oregon Health & Science University, Portland, Oregon
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Affiliation(s)
- Jason J Han
- From the Department of Surgery, Division of Cardiovascular Surgery (J.J.H.), and the Department of Anesthesiology and Critical Care (J.M.R.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jesse M Raiten
- From the Department of Surgery, Division of Cardiovascular Surgery (J.J.H.), and the Department of Anesthesiology and Critical Care (J.M.R.), Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Giang C, Calvert J, Rahmani K, Barnes G, Siefkas A, Green-Saxena A, Hoffman J, Mao Q, Das R. Predicting ventilator-associated pneumonia with machine learning. Medicine (Baltimore) 2021; 100:e26246. [PMID: 34115013 PMCID: PMC8202554 DOI: 10.1097/md.0000000000026246] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/02/2021] [Indexed: 01/04/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) is the most common and fatal nosocomial infection in intensive care units (ICUs). Existing methods for identifying VAP display low accuracy, and their use may delay antimicrobial therapy. VAP diagnostics derived from machine learning (ML) methods that utilize electronic health record (EHR) data have not yet been explored. The objective of this study is to compare the performance of a variety of ML models trained to predict whether VAP will be diagnosed during the patient stay.A retrospective study examined data from 6126 adult ICU encounters lasting at least 48 hours following the initiation of mechanical ventilation. The gold standard was the presence of a diagnostic code for VAP. Five different ML models were trained to predict VAP 48 hours after initiation of mechanical ventilation. Model performance was evaluated with regard to the area under the receiver operating characteristic (AUROC) curve on a 20% hold-out test set. Feature importance was measured in terms of Shapley values.The highest performing model achieved an AUROC value of 0.854. The most important features for the best-performing model were the length of time on mechanical ventilation, the presence of antibiotics, sputum test frequency, and the most recent Glasgow Coma Scale assessment.Supervised ML using patient EHR data is promising for VAP diagnosis and warrants further validation. This tool has the potential to aid the timely diagnosis of VAP.
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Volbeda M, Jou-Valencia D, van den Heuvel MC, Knoester M, Zwiers PJ, Pillay J, Berger SP, van der Voort PHJ, Zijlstra JG, van Meurs M, Moser J. Comparison of renal histopathology and gene expression profiles between severe COVID-19 and bacterial sepsis in critically ill patients. Crit Care 2021; 25:202. [PMID: 34112226 PMCID: PMC8190989 DOI: 10.1186/s13054-021-03631-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/06/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The mechanisms driving acute kidney injury (AKI) in critically ill COVID-19 patients are unclear. We collected kidney biopsies from COVID-19 AKI patients within 30 min after death in order to examine the histopathology and perform mRNA expression analysis of genes associated with renal injury. METHODS This study involved histopathology and mRNA analyses of postmortem kidney biopsies collected from patients with COVID-19 (n = 6) and bacterial sepsis (n = 27). Normal control renal tissue was obtained from patients undergoing total nephrectomy (n = 12). The mean length of ICU admission-to-biopsy was 30 days for COVID-19 and 3-4 days for bacterial sepsis patients. RESULTS We did not detect SARS-CoV-2 RNA in kidney biopsies from COVID-19-AKI patients yet lung tissue from the same patients was PCR positive. Extensive acute tubular necrosis (ATN) and peritubular thrombi were distinct histopathology features of COVID-19-AKI compared to bacterial sepsis-AKI. ACE2 mRNA levels in both COVID-19 (fold change 0.42, p = 0.0002) and bacterial sepsis patients (fold change 0.24, p < 0.0001) were low compared to control. The mRNA levels of injury markers NGAL and KIM-1 were unaltered compared to control tissue but increased in sepsis-AKI patients. Markers for inflammation and endothelial activation were unaltered in COVID-19 suggesting a lack of renal inflammation. Renal mRNA levels of endothelial integrity markers CD31, PV-1 and VE-Cadherin did not differ from control individuals yet were increased in bacterial sepsis patients (CD31 fold change 2.3, p = 0.0006, PV-1 fold change 1.5, p = 0.008). Angiopoietin-1 mRNA levels were downregulated in renal tissue from both COVID-19 (fold change 0.27, p < 0.0001) and bacterial sepsis patients (fold change 0.67, p < 0.0001) compared to controls. Moreover, low Tie2 mRNA expression (fold change 0.33, p = 0.037) and a disturbed VEGFR2/VEGFR3 ratio (fold change 0.09, p < 0.0001) suggest decreased microvascular flow in COVID-19. CONCLUSIONS In a small cohort of postmortem kidney biopsies from COVID-19 patients, we observed distinct histopathological and gene expression profiles between COVID-19-AKI and bacterial sepsis-AKI. COVID-19 was associated with more severe ATN and microvascular thrombosis coupled with decreased microvascular flow, yet minimal inflammation. Further studies are required to determine whether these observations are a result of true pathophysiological differences or related to the timing of biopsy after disease onset.
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Affiliation(s)
- Meint Volbeda
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Daniela Jou-Valencia
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Marius C van den Heuvel
- Department of Pathology and Medical Biology, Pathology Section, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolein Knoester
- Department of Clinical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Peter J Zwiers
- Department of Pathology and Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine and Vascular Drug Targeting Research, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Janesh Pillay
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Stefan P Berger
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter H J van der Voort
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Jan G Zijlstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Pathology and Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine and Vascular Drug Targeting Research, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Pathology and Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine and Vascular Drug Targeting Research, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jill Moser
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
- Department of Pathology and Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine and Vascular Drug Targeting Research, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Thoral PJ, Peppink JM, Driessen RH, Sijbrands EJG, Kompanje EJO, Kaplan L, Bailey H, Kesecioglu J, Cecconi M, Churpek M, Clermont G, van der Schaar M, Ercole A, Girbes ARJ, Elbers PWG. Sharing ICU Patient Data Responsibly Under the Society of Critical Care Medicine/European Society of Intensive Care Medicine Joint Data Science Collaboration: The Amsterdam University Medical Centers Database (AmsterdamUMCdb) Example. Crit Care Med 2021; 49:e563-e577. [PMID: 33625129 PMCID: PMC8132908 DOI: 10.1097/ccm.0000000000004916] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Critical care medicine is a natural environment for machine learning approaches to improve outcomes for critically ill patients as admissions to ICUs generate vast amounts of data. However, technical, legal, ethical, and privacy concerns have so far limited the critical care medicine community from making these data readily available. The Society of Critical Care Medicine and the European Society of Intensive Care Medicine have identified ICU patient data sharing as one of the priorities under their Joint Data Science Collaboration. To encourage ICUs worldwide to share their patient data responsibly, we now describe the development and release of Amsterdam University Medical Centers Database (AmsterdamUMCdb), the first freely available critical care database in full compliance with privacy laws from both the United States and Europe, as an example of the feasibility of sharing complex critical care data. SETTING University hospital ICU. SUBJECTS Data from ICU patients admitted between 2003 and 2016. INTERVENTIONS We used a risk-based deidentification strategy to maintain data utility while preserving privacy. In addition, we implemented contractual and governance processes, and a communication strategy. Patient organizations, supporting hospitals, and experts on ethics and privacy audited these processes and the database. MEASUREMENTS AND MAIN RESULTS AmsterdamUMCdb contains approximately 1 billion clinical data points from 23,106 admissions of 20,109 patients. The privacy audit concluded that reidentification is not reasonably likely, and AmsterdamUMCdb can therefore be considered as anonymous information, both in the context of the U.S. Health Insurance Portability and Accountability Act and the European General Data Protection Regulation. The ethics audit concluded that responsible data sharing imposes minimal burden, whereas the potential benefit is tremendous. CONCLUSIONS Technical, legal, ethical, and privacy challenges related to responsible data sharing can be addressed using a multidisciplinary approach. A risk-based deidentification strategy, that complies with both U.S. and European privacy regulations, should be the preferred approach to releasing ICU patient data. This supports the shared Society of Critical Care Medicine and European Society of Intensive Care Medicine vision to improve critical care outcomes through scientific inquiry of vast and combined ICU datasets.
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Affiliation(s)
- Patrick J Thoral
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Vrije Universiteit, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Jan M Peppink
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Vrije Universiteit, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Ronald H Driessen
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Vrije Universiteit, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | | | - Erwin J O Kompanje
- Department of Intensive Care Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Lewis Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Executive Committee, Society of Critical Care Medicine, Mount Prospect, IL
| | - Heatherlee Bailey
- Department of Emergency Medicine, Durham VA Medical Center, Durham, NC
- Executive Committee, Society of Critical Care Medicine, Mount Prospect, IL
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Executive Committee, European Society of Intensive Care Medicine, Brussels, Belgium
| | - Maurizio Cecconi
- Executive Committee, European Society of Intensive Care Medicine, Brussels, Belgium
- Department of Anaesthesia and Intensive Care, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Matthew Churpek
- Department of Medicine, University of Wisconsin, Madison, WI
| | - Gilles Clermont
- Department of Critical Care Medicine, CRISMA Laboratory, University of Pittsburgh, Pittsburgh, PA
| | - Mihaela van der Schaar
- University of Cambridge, Cambridge, United Kingdom
- Alan Turing Institute, London, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
- Data Science Section, European Society of Intensive Care Medicine, Brussels, Belgium
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Vrije Universiteit, Universiteit van Amsterdam, Amsterdam, The Netherlands
- Executive Committee, European Society of Intensive Care Medicine, Brussels, Belgium
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Vrije Universiteit, Universiteit van Amsterdam, Amsterdam, The Netherlands
- Data Science Section, European Society of Intensive Care Medicine, Brussels, Belgium
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Abstract
IMPORTANCE Sepsis is associated with a high burden of inpatient mortality. Treatment in intensive care units (ICUs) that have more experience treating patients with sepsis may be associated with lower mortality. OBJECTIVE To assess the association between the volume of patients with sepsis receiving care in an ICU and hospital mortality from sepsis in the UK. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from adult patients with sepsis from 231 UK ICUs between 2010 and 2016. Demographic and clinical data were extracted from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme database. Data were analyzed from January 1, 2010, to December 31, 2016. EXPOSURES Annual sepsis case volume in an ICU in the year of a patient's admission. MAIN OUTCOMES AND MEASURES Hospital mortality after ICU admission for sepsis assessed using a mixed-effects logistic model in a 3-level hierarchical structure based on the number of individual patients nested in years nested within ICUs. RESULTS Among 273 001 patients included in the analysis, the median age was 66 years (interquartile range, 53-76 years), 148 149 (54.3%) were male, and 248 275 (91.0%) were White. The mean ICNARC-2018 illness severity score was 21.0 (95% CI, 20.9-21.0). Septic shock accounted for 19.3% of patient admissions, and 54.3% of patients required mechanical ventilation. The median annual sepsis volume per ICU was 242 cases (interquartile range, 177-334 cases). The study identified a significant association between the volume of sepsis cases in the ICU and mortality from sepsis; in the logistic regression model, hospital mortality was significantly lower among patients admitted to ICUs in the highest quartile of sepsis volume compared with the lowest quartile (odds ratio [OR], 0.89; 95% CI, 0.82-0.96; P = .002). With volume modeled as a restricted cubic spline, treatment in a larger ICU was associated with lower hospital mortality. A lower annual volume threshold of 215 patients above which hospital mortality decreased significantly was found; 38.8% of patients were treated in ICUs below this threshold volume. There was no significant interaction between ICU volume and severity of illness as described by the ICNARC-2018 score (β [SE], -0.00014 [0.00024]; P = .57). CONCLUSIONS AND RELEVANCE The findings suggest that patients with sepsis in the UK have higher odds of survival if they are treated in an ICU with a larger sepsis case volume. The benefit of a high sepsis case volume was not associated with the severity of the sepsis episode.
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Affiliation(s)
- Ritesh Maharaj
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Department of Critical Care, Kings College Hospital NHS Foundation Trust, London, UK
| | - Alistair McGuire
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics and Political Science, London, UK
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Giuliano KK, Penoyer D, Middleton A, Baker D. Original Research: Oral Care as Prevention for Nonventilator Hospital-Acquired Pneumonia: A Four-Unit Cluster Randomized Study. Am J Nurs 2021; 121:24-33. [PMID: 33993136 DOI: 10.1097/01.naj.0000753468.99321.93] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Nonventilator hospital-acquired pneumonia (NV-HAP) presents a serious and largely preventable threat to patient safety in U.S. hospitals. There is an emerging body of evidence on the effectiveness of oral care in preventing NV-HAP. PURPOSE The primary aim of this study was to determine the effectiveness of a universal, standardized oral care protocol in preventing NV-HAP in the acute care setting. The primary outcome measure was NV-HAP incidence per 1,000 patient-days. METHODS This 12-month study was conducted on four units at an 800-bed tertiary medical center. Patients on one medical and one surgical unit were randomly assigned to receive enhanced oral care (intervention units); patients on another medical and another surgical unit received usual oral care (control units). RESULTS Total enrollment was 8,709. For the medical control versus intervention units, oral care frequency increased from a mean of 0.95 to 2.25 times per day, and there was a significant 85% reduction in the NV-HAP incidence rate. The odds of developing NV-HAP were 7.1 times higher on the medical control versus intervention units, a significant finding. For the surgical control versus intervention units, oral care frequency increased from a mean of 1.18 to 2.02 times per day, with a 56% reduction in the NV-HAP incidence rate. The odds of developing NV-HAP were 1.6 times higher on the surgical control versus intervention units, although this result did not reach significance. CONCLUSIONS These findings add to the growing body of evidence that daily oral care as a means of primary source control may have a role in NV-HAP prevention. The implementation of effective strategies to ensure that such care is consistently provided warrants further study. It's not yet known what degree and frequency of oral care are required to effect favorable changes in the oral microbiome during acute care hospitalization.
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Affiliation(s)
- Karen K Giuliano
- Karen K. Giuliano is an associate professor at the College of Nursing and the Institute for Applied Life Sciences, University of Massachusetts Amherst. Daleen Penoyer is the director of the Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL. Aurea Middleton is the research coordinator for Orlando Health's Center for Nursing Research. Dian Baker is a professor at the School of Nursing, California State University, Sacramento. Financial support for this study was provided by Medline Industries (which supplied the kits used) and Orlando Health. Baker and Giuliano have also created a CE program on NV-HAP sponsored by Medline. An intervention toolkit is available from the authors. The authors acknowledge Joohyun Chung for her guidance and review of the statistical approach and analyses. Contact author: Karen K. Giuliano, . The authors have disclosed no other potential conflicts of interest, financial or otherwise
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Nagata I, Abe T, Ogura H, Kushimoto S, Fujishima S, Gando S. Intensive care unit model and in-hospital mortality among patients with severe sepsis and septic shock: A secondary analysis of a multicenter prospective observational study. Medicine (Baltimore) 2021; 100:e26132. [PMID: 34032762 PMCID: PMC8154476 DOI: 10.1097/md.0000000000026132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 05/06/2021] [Indexed: 01/04/2023] Open
Abstract
We aimed to determine the association between the intensive care unit (ICU) model and in-hospital mortality of patients with severe sepsis and septic shock.This was a secondary analysis of a multicenter prospective observational study conducted in 59 ICUs in Japan from January 2016 to March 2017. We included adult patients (aged ≥16 years) with severe sepsis and septic shock based on the sepsis-2 criteria who were admitted to an ICU with a 1:2 nurse-to-patient ratio per shift. Patients were categorized into open or closed ICU groups, according to the ICU model. The primary outcome was in-hospital mortality.A total of 1018 patients from 45 ICUs were included in this study. Patients in the closed ICU group had a higher severity score and higher organ failure incidence than those in the open ICU group. The compliance rate for the sepsis care 3-h bundle was higher in the closed ICU group than in the open ICU group. In-hospital mortality was not significantly different between the closed and open ICU groups in a multilevel logistic regression analysis (odds ratio = 0.83, 95% confidence interval; 0.52-1.32, P = .43) and propensity score matching analysis (closed ICU, 21.2%; open ICU, 25.7%, P = .22).In-hospital mortality between the closed and open ICU groups was not significantly different after adjusting for ICU structure and compliance with the sepsis care bundle.
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Affiliation(s)
- Isao Nagata
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa
| | - Toshikazu Abe
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Ibaraki
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Ibaraki
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Osaka
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Tokyo
| | - Satoshi Gando
- Intensive Care Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
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Wang Q, Xuan Y, Liu C, Lu M, Liu Z, Chang P. Blind placement of postpyloric feeding tubes at the bedside in intensive care. Crit Care 2021; 25:168. [PMID: 33975642 PMCID: PMC8111987 DOI: 10.1186/s13054-021-03587-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/27/2021] [Indexed: 04/08/2023] Open
Affiliation(s)
- Qianwen Wang
- Department of Critical Care Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Middle Avenue, Haizhu District, Guangzhou, 510280, Guangdong, China
| | - Yongbo Xuan
- Department of Critical Care Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Middle Avenue, Haizhu District, Guangzhou, 510280, Guangdong, China
| | - Cuiping Liu
- Department of Critical Care Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Middle Avenue, Haizhu District, Guangzhou, 510280, Guangdong, China
| | - Mei Lu
- Department of Critical Care Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Middle Avenue, Haizhu District, Guangzhou, 510280, Guangdong, China
| | - Zhanguo Liu
- Department of Critical Care Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Middle Avenue, Haizhu District, Guangzhou, 510280, Guangdong, China.
| | - Ping Chang
- Department of Critical Care Medicine, Zhujiang Hospital, Southern Medical University, 253 Gongye Middle Avenue, Haizhu District, Guangzhou, 510280, Guangdong, China.
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Marwaha JS, Terzic CM, Kennedy DJ, Halamka J, Brat GA. Overwhelmed Hospitals May Soon Lead to Overwhelmed Rehabilitation Facilities Unless Post-Acute Care Infrastructure Is Strengthened. Am J Phys Med Rehabil 2021; 100:441-442. [PMID: 33819926 DOI: 10.1097/phm.0000000000001737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Morale W, Sessa C, Alessandrello I, Aprile G, Galeano D, Giglio E, Ficara V, Musumeci S, Scollo V, Zuppardo C, Baglieri A, Rizza G, Bonomo P, Modica S, Patriarca G, Elia R, Aliquò A, Musso S. [The management of nephropathic patients during the Covid-19 pandemic: the experience of Ragusa]. G Ital Nefrol 2021; 38:38-02-2021-05. [PMID: 33852221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The public emergency caused by Covid-19 has forced health services to reorganize in order to separate positive patients from negative ones. In nephrology, this reorganization involves several levels of assistance concerning hospitalizations, ambulatory care and haemodialysis. Within the Complex Unit of Nephrology in Ragusa, the distribution of nephro-dialytic resources has involved four different hospitals, hence ensuring haemodialysis services for asymptomatic and pauci-symptomatic Covid-19 patients as well as for patients in Covid-Unit, Sub-Intensive Therapy and Intensive Care Unit. In this complex context, we had to create a common protocol involving all the professionals who provide assistance in our Unit, across the different structures. We also report some encouraging data that seem to indicate the effectiveness of the protocols put in place.
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Affiliation(s)
- Walter Morale
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Concetto Sessa
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Ivana Alessandrello
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Giorgio Aprile
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Dario Galeano
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Elisa Giglio
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Vincenzo Ficara
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Stella Musumeci
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Viviana Scollo
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Carmelo Zuppardo
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Andrea Baglieri
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Giovanni Rizza
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Pietro Bonomo
- Direzione Sanitaria Ospedale "Maggiore", Modica (RG), Italy
| | | | - Giuseppe Patriarca
- Direzione Generale Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Raffaele Elia
- Direzione Generale Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Angelo Aliquò
- Direzione Generale Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
| | - Salvatore Musso
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa, Italy
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Gaudry S, Hajage D, Martin-Lefevre L, Lebbah S, Louis G, Moschietto S, Titeca-Beauport D, Combe BL, Pons B, de Prost N, Besset S, Combes A, Robine A, Beuzelin M, Badie J, Chevrel G, Bohé J, Coupez E, Chudeau N, Barbar S, Vinsonneau C, Forel JM, Thevenin D, Boulet E, Lakhal K, Aissaoui N, Grange S, Leone M, Lacave G, Nseir S, Poirson F, Mayaux J, Asehnoune K, Geri G, Klouche K, Thiery G, Argaud L, Rozec B, Cadoz C, Andreu P, Reignier J, Ricard JD, Quenot JP, Dreyfuss D. Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial. Lancet 2021; 397:1293-1300. [PMID: 33812488 DOI: 10.1016/s0140-6736(21)00350-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/21/2020] [Accepted: 02/03/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Delaying renal replacement therapy (RRT) for some time in critically ill patients with severe acute kidney injury and no severe complication is safe and allows optimisation of the use of medical devices. Major uncertainty remains concerning the duration for which RRT can be postponed without risk. Our aim was to test the hypothesis that a more-delayed initiation strategy would result in more RRT-free days, compared with a delayed strategy. METHODS This was an unmasked, multicentre, prospective, open-label, randomised, controlled trial done in 39 intensive care units in France. We monitored critically ill patients with severe acute kidney injury (defined as Kidney Disease: Improving Global Outcomes stage 3) until they had oliguria for more than 72 h or a blood urea nitrogen concentration higher than 112 mg/dL. Patients were then randomly assigned (1:1) to either a strategy (delayed strategy) in which RRT was started just after randomisation or to a more-delayed strategy. With the more-delayed strategy, RRT initiation was postponed until mandatory indication (noticeable hyperkalaemia or metabolic acidosis or pulmonary oedema) or until blood urea nitrogen concentration reached 140 mg/dL. The primary outcome was the number of days alive and free of RRT between randomisation and day 28 and was done in the intention-to-treat population. The study is registered with ClinicalTrial.gov, NCT03396757 and is completed. FINDINGS Between May 7, 2018, and Oct 11, 2019, of 5336 patients assessed, 278 patients underwent randomisation; 137 were assigned to the delayed strategy and 141 to the more-delayed strategy. The number of complications potentially related to acute kidney injury or to RRT were similar between groups. The median number of RRT-free days was 12 days (IQR 0-25) in the delayed strategy and 10 days (IQR 0-24) in the more-delayed strategy (p=0·93). In a multivariable analysis, the hazard ratio for death at 60 days was 1·65 (95% CI 1·09-2·50, p=0·018) with the more-delayed versus the delayed strategy. The number of complications potentially related to acute kidney injury or renal replacement therapy did not differ between groups. INTERPRETATION In severe acute kidney injury patients with oliguria for more than 72 h or blood urea nitrogen concentration higher than 112 mg/dL and no severe complication that would mandate immediate RRT, longer postponing of RRT initiation did not confer additional benefit and was associated with potential harm. FUNDING Programme Hospitalier de Recherche Clinique.
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Affiliation(s)
- Stéphane Gaudry
- Département de réanimation médico-chirurgicale, APHP Hôpital Avicenne, Bobigny, France; Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France; Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France; Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Bobigny, France
| | - David Hajage
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
| | | | - Saïd Lebbah
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
| | - Guillaume Louis
- Réanimation polyvalente, CHR Metz-Thionville Hôpital de Mercy, Metz, France
| | | | | | | | - Bertrand Pons
- Réanimation, CHU Pointe-à-Pitre-Abymes, Pointe-a-Pitre, France
| | | | - Sébastien Besset
- Université de Paris, APHP, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive-Réanimation, Colombes, France
| | - Alain Combes
- Service de Réanimation Médicale, Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
| | - Adrien Robine
- Réanimation Soins continus, CH de Bourg-en-Bresse-Fleyriat, 01012 Bourg-en-Bresse, France
| | | | - Julio Badie
- Réanimation polyvalente, Hôpital Nord Franche-Comte CH Belfort, Belfort, France
| | | | - Julien Bohé
- Anesthésie réanimation médicale et chirurgicale, CH Lyon Sud, Pierre Benite
| | - Elisabeth Coupez
- Réanimation polyvalente, Hôpital G. Montpied, Clermont Ferrand, France
| | - Nicolas Chudeau
- Réanimation médico-chirurgicale, CH du Mans, Le Mans, France
| | | | | | | | | | - Eric Boulet
- Réanimation et USC, GH Carnelle Portes de l'Oise, Beaumont sur Oise, France
| | - Karim Lakhal
- Réanimation chirurgicale polyvalente, Hôpital Nord laennec, Nantes, France
| | - Nadia Aissaoui
- Réanimation médicale, Hôpital Georges Pompidou, Paris, France
| | | | - Marc Leone
- Anesthésie Réanimation, Hôpital Nord, Marseille, France
| | - Guillaume Lacave
- Réanimation médico-chirurgicale, Hôpital André Mignot, Versailles, France
| | - Saad Nseir
- Réanimation médicale, CHRU de Lille, Hôpital Roger Salengro, Lille, France
| | - Florent Poirson
- Département de réanimation médico-chirurgicale, APHP Hôpital Avicenne, Bobigny, France
| | - Julien Mayaux
- Pneumologie et Réanimation médicale, Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
| | | | - Guillaume Geri
- Réanimation médico-chirurgicale, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Kada Klouche
- Médecine Intensive Réanimation, Hôpital Lapeyronnie, Montpellier, France
| | - Guillaume Thiery
- Réanimation médicale, CHU Saint Etienne, Saint Priest en Jarez, France
| | - Laurent Argaud
- Réanimation médicale, Hôpital Edouard Herriot, Lyon, France
| | | | - Cyril Cadoz
- Réanimation polyvalente, CHR Metz-Thionville Hôpital de Mercy, Metz, France
| | - Pascal Andreu
- Médecine intensive réanimation, Hôtel Dieu, Nantes, France
| | - Jean Reignier
- Médecine intensive réanimation, Hôtel Dieu, Nantes, France
| | - Jean-Damien Ricard
- Université de Paris, APHP, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive-Réanimation, Colombes, France; INSERM, IAME, U1137, Paris, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France; Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France; INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Didier Dreyfuss
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France; Université de Paris, APHP, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive-Réanimation, Colombes, France.
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