Effect of mobility at ICU discharge on mortality and length of post-ICU stay: A retrospective analysis

Purpose Mobilisation is a common intervention in Intensive Care (ICU). However, few studies have explored the relationship between mobility levels and outcomes. This study assessed the association of the level of mobility on ICU discharge with discharge destination from the hospital and hospital length of stay. Materials and methods A retrospective analysis of data from 522 patients admitted to a single UK general ICU who were ventilated for ≥5 days was performed. The level of mobility was assessed using the Manchester Mobility Score (MMS). Multivariable regression analysed demographic and clinical variables for the independence of association with discharge destination and hospital length of stay. Results MMS ≥5 on ICU discharge was independently associated with discharge destination and hospital LOS (p < 0.001). Patients achieving MMS ≥5 on ICU discharge were more likely to be discharged home (OR 3.86 95% CI 2.1 to 6.9, p < 0.001), and had an 11.8 day shorter hospital LOS (95% CI −17.6 to −6.1, p < 0.001). Conclusions The ability to step transfer to a chair (MMS ≥5) before ICU discharge was independently associated with discharge to usual residence and hospital LOS, irrespective of preadmission morbidity. Increasing the level of patient mobility at ICU discharge should be a key focus of rehabilitation interventions.

New study further questions PPIs superiority over H2RAs for stress ulcer prophylaxis

Purpose Patients who step to a chair on ICU discharge experience better post-intensive care unit (ICU) management and in-hospital outcomes. Evidence identifying patients more or less likely to achieve this milestone is limited. This service evaluation identifies factors associated with achieving a step transfer on ICU discharge and explores its relationship with rehabilitation delivery. Materials and methods A retrospective analysis of 355 consecutive patients admitted to a UK general ICU for ≥5 days was conducted. Multivariable logistic regression analysed demographic and clinical variables for independence of association with achieving a step to a chair (Manchester Mobility Score [MMS] ≥ 5) on ICU discharge. Results Absence of ICU-Acquired Weakness (ICU-AW) was independently associated with achieving MMS ≥5 on ICU discharge (OR 6.09 95% CI 1.24 to 29.80 p = 0.03). Patients achieving MMS ≥5 on first mobility utilised less rehabilitation resource (MMS ≥5 4 sessions vs MMS ≤4 7, p < 0.001), achieving higher discharge mobility levels (MMS 7 vs 5, p < 0.001) in a shorter time frame (3 days vs 6, p < 0.001). Conclusions Rehabilitation interventions should be prioritised for patients presenting with ICU-AW. Resources should be reappropriated to patients not achieving MMS ≥5 on their first mobility in ICU, to deliver impairment focussed and individualised rehabilitation.

Critical COVID-19 is a life-threatening disease characterized by severe hypoxemia with complex pathophysiological mechanisms that are not yet completely understood. A pathological shift in the oxyhemoglobin curve (ODC) was previously described through the analysis of p50, intended as the oxygen tension at which hemoglobin is saturated by oxygen at 50%. The aim of this study was to analyze Hb-O2 affinity features over time in a cohort of critically ill COVID-19 patients, through the analysis of ODC p50 behavior. A retrospective analysis was performed; through multiple arterial blood gas (ABG) analyses, each p50 was calculated and normalized according to PaCO2, pH and temperature; patients’ p50 evolution over time was reported, comparing the first 3 days (early p50s) with the last 3 days (late p50s) of ICU stay. A total of 3514 ABG analyses of 32 consecutive patients were analyzed. The majority of patients presented a left shift over time (p = 0.03). A difference between early p50s and late p50s was found (20.63 ± 2.1 vs. 18.68 ± 3.3 mmHg, p = 0.03); median p50 of deceased patients showed more right shifts than those of alive patients (24.1 vs. 18.45 mmHg, p = 0.01). One-way ANOVA revealed a p50 variance greater in the early p50s (σ2 = 8.6) than in the late p50s (σ2 = 3.84), associated with a reduction over time (p < 0.001). Comparing the Hb-O2 affinity in critically ill COVID-19 patients between ICU admission and ICU discharge, a temporal shift in the ODC was observed.

The objective of this observational study was to evaluate whether early intervention was associated with improved long-term outcomes in critically ill patients with cancer. Retrospective analysis with prospectively collected data. A university-affiliated, tertiary referral hospital. Consecutive critically ill cancer patients who were managed by a medical emergency team before ICU admission between January 2010 and December 2012. None. During the study period, 525 critically ill cancer patients were admitted to the ICU with respiratory failure (41.7%) and severe sepsis or septic shock (40.6%) following medical intervention by a medical emergency team. Of 356 ICU survivors, 161 (45.2%) received additional treatment for cancer after ICU discharge. Mortality was 66.1% at 6 months and 72.8% at 1 year. Median time from physiological derangement to intervention before ICU admission was significantly shorter in 1-year survivors (1.3 hr; interquartile range, 0.5-4.8 hr) than it was in nonsurvivors (2.9 hr; interquartile range, 0.8-9.6 hr) (p< 0.001). Additionally, the early intervention (≤ 1.5 hr) group had a lower 30-day mortality rate than the late intervention (> 1.5 hr) group (29.0% vs 55.3%; p < 0.001) and a similar difference in mortality rate was observed up to 1 year. Other factors associated with 1-year mortality were illness severity, performance status, malignancy status, presence of more than three abnormal physiological variables, time from derangement to ICU admission, and the need for mechanical ventilation. Even after adjusting for potential confounding factors, early intervention was significantly associated with 1-year mortality (adjusted hazard ratio, 0.456; 95% CI, 0.348-0.597; p < 0.001). Early intervention for clinical derangement on general wards was significantly associated with long-term outcomes in critically ill cancer patients.

AimCardiac arrest is the most serious complication in acute coronary syndromes. Glycoprotein IIb/IIIa inhibitors (GPI) are used in selected acute coronary syndrome patients. If the use of GPI leads to an increase in bleeding events and influences survival in patients after cardiac arrest is unknown.MethodsWe report retrospective data of a single center registry of patients after successful intra- and out-of-hospital cardiac arrest between 2002 and 2013. Inclusion criteria were survival for at least 6 h and successful percutaneous coronary intervention (PCI) within the first 24 h. Patients treated with other fibrinolytic agents or being supported by an extracorporeal life support system were excluded from the analysis.Results310 patients were included in our study. 204 received GPI (GPI+), 106 did not (GPI−). Patients in the GPI+ group were significantly younger (62.8 vs. 68.0 years, p < 0.001) and had larger myocardial infarction sizes (maximum creatine kinase 3407 vs. 1450 U/l, p < 0.001). CPR duration, SOFA score and first lactate did not differ between the groups. Any bleeding occurred significantly more often in the GPI+ group (83.3% vs. 67.0%, p = 0.001). Decline of hemoglobin within the first 24 h was higher in the GPI+ group (−1.59 ± 1.71 mg/dl vs. −0.88 ± 1.95 mg/dl, p = 0.004), number of transfused packed red blood cells in the first 4 days, however, were similar (1.18 ± 0.40 vs. 0.90 ± 0.41 packs, p = 0.378). Survival at ICU discharge was significantly higher in the GPI+ group (77.5% vs. 63.2%, p = 0.008). The use of GPI was an independent predictor of hospital survival (OR 3.07, CI 1.31−7.20, p = 0.010). The positive effect for GPI persisted after nearest neighbor propensity score matching including 144 patients (OR 3.27, 95% CI 1.48−7.21, p = 0.003).ConclusionAfter cardiac arrest, bleeding incidence was significantly higher in patients treated with GPI. Incidence of bleedings requiring transfusion, however, was similar. In this retrospective analysis, the use of GPI was an independent predictor of hospital survival. We suggest that GPI may not be withheld from cardiac arrest survivors due to potential risk of bleeding.Graphic abstract

Racial and gender disparities in end-of-life decision-making practices have not been well described in surgical patients. We performed an eight-year retrospective analysis of surgical patients within the Cerner Acute Physiology and Chronic Health Evaluation Outcomes database. ICU patients with documented admission code status, and death or ICU discharge code status, respectively, were included. Logistic regression analysis was performed to assess change in code status. Of 468,000 ICU patients, 97,968 (20.9%) were surgical, 63,567 (95%) survived, and 3,343 (5%) died during their hospitalization. Of those, 50,915 (80.1%) and 2,625 (78.5%) had complete code status data on admission and discharge or death, respectively. Women were less likely than men to remain full code at ICU discharge and death (n = 20,940, 95.6% and n = 141, 11.9% vs n = 29,320, 97.4% and n = 233, 16.3%, P < 0.001). Compared with whites, blacks and other minorities had a 0.46 odds (95% confidence interval [CI]: 0.33-0.64, P < 0.001) and 0.54 odds (95% CI: 0.34-0.85, P = 0.01) of changing from full code status before death, respectively. Before ICU discharge, blacks and other minorities had a 0.56 odds of changing from full code status when compared with whites (95% CI: 0.40-0.79, P < 0.001 vs 95% CI: 0.36-0.87, P = 0.01, respectively). Women were more likely to be discharged or die after a change in code status from full code (odds ratio 1.27, 95% CI: 1.06-1.07, P < 0.001; odds ratio 1.39, 95% CI: 1.09-1.79, P = 0.009). Men and minorities are more likely to be discharged from the ICU or die with a full code status designation.

EVALUATION OF FLUID BALANCE IN ADULT PATIENTS WITH SEPSIS

Chronic pain after COVID-19: implications for rehabilitation

Background: In this study, we aimed to retrospectively evaluate the demographic data, clinical diagnoses, laboratory values and scoring systems that may be effective in predicting mortality in patients undergoing continuous renal replacement therapy (CRRT) in our intensive care unit. Materials and Methods: The data of patients who underwent CRRT in our tertiary intensive care unit were retrospectively analyzed. Digital archive data of Intensive Care Units, patients' medical history, laboratory results and nurse observation forms were analyzed. Acute Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma score (GCS), Sequential Organ Failure Assessment (SOFA), Crp/Albumin ratio were analyzed at four time points (during ICU admission, before CRRT, after CRRT and discharge) and their effects on mortality were compared. Results: A total of 107 patients were included in our study between 2017 and 2022 and 101 of these cases resulted in mortality. The change in CRP/Albumin values and GCS scores after CRRT compared to before CRRT was not significant (p&amp;gt;0.05), but the decrease in APACHE II (p&amp;lt;0.01) and SOFA (p&amp;lt;0.01) scores were found to be significant in predicting mortality. No significant difference was found in terms of gender and body mass index measurements, use of inotropic agents, length of intensive care unit stay, length of hospital stay and comorbidities (p&amp;gt;0.05). However, age was found to be a risk factor for mortality (p&amp;lt;0.01). Conclusion: Although CRRT is performed in intensive care unit patients for many underlying causes and can improve APACHE II and SOFA scores, no statistically significant relationship was found be-tween CRP/Albumin ratio in predicting the effect of CRRT on mortality

Unplanned readmission of hospitalized patients to an ICU is associated with an increased mortality and hospital length of stay. The ability to identify patients at risk, who would benefit from prolonged ICU treatment, is limited. The aim of this study is to validate a previously published numerical index named the Stability and Workload Index for Transfer in a heterogeneous group of ICU patients. In this retrospective data analysis, the Stability and Workload Index for Transfer score was calculated for all patients, and the ability of the score to predict readmission was compared with the original publication. Four ICUs, one intermediate care unit, and one postanesthesia care unit of the department of anesthesia and intensive care of a university hospital. All consecutive patients treated in one of the units. None. Unplanned ICU readmissions or unexpected death within 7 days of ICU discharge. The data of 7,175 patients were included in the analysis. Five hundred ninety-six patients were readmitted or died within 7 days of discharge. The patients who are readmitted to the ICU are significantly older and have significantly higher scores that define the severity of disease at the time of admission and discharge of their first ICU stay. The source of admission for the initial ICU stay did not differ (p = 0.055), and the last Glasgow Coma Scale and the last PaO2/FIO2 ratio before discharge from the ICU were higher in patients who did not need a readmission to the ICU. The performance of the Stability and Workload Index for Transfer score is poor with an area under the receiver operator curve of 0.581 (95% CI, 0.556-0.605; p < 0.001). Based on the data from our patients, the proposed Stability and Workload Index for Transfer score by Gajic et al is not ideal in aiding the clinician in the decision, if a patient can be discharged safely from the ICU and further research is necessary to define the patients at risk for readmission.

Prone Positioning During Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome-Better Together?

IntroductionPlasma selenium (Se) concentrations are reduced in critically ill surgical patients, and lower plasma Se concentrations are associated with worse outcomes. We investigated whether adjuvant Se supplementation in the form of sodium selenite could improve outcomes in surgical patients with sepsis.MethodsIn this retrospective study, all adult patients admitted to a 50-bed surgical ICU with severe sepsis between January 2004 and April 2010 were included and analysed according to whether they had received adjuvant Se supplementation, which was given at the discretion of the attending physician. When prescribed, Se was administered in the form of sodium selenite pentahydrate (Na2SeO3∙5H2O), in which 100 μg of Se corresponds to 333 μg of sodium selenite. A bolus of sodium selenite corresponding to 1,000 μg of Se was injected intravenously through a central venous line for 30 minutes, followed by infusion of 1,000 μg/day for 24 hours for 14 days until ICU discharge or death. We performed logistic regression analysis to investigate the impact of adjuvant Se supplementation on hospital mortality.ResultsAdjuvant Se was administered to 413 (39.7%) of the 1,047 patients admitted with severe sepsis. Age and sex were similar between patients who received adjuvant Se and those who did not. Compared with patients who did not receive adjuvant Se supplementation, patients who did had higher scores on the Simplified Acute Physiology Score II, a greater prevalence of cancer upon admission to the ICU and were more commonly admitted after abdominal surgery. Compared with patients who did not receive adjuvant Se, patients who did had higher hospital mortality rates (46% versus 39.1%; P = 0.027), and longer median (interquartile range (IQR)) ICU stays (15 days (6 to 24) versus 11 days (4 to 24); P = 0.01) and hospital lengths of stay (33 days (21 to 52) versus 28 days (17 to 46); P = 0.001). In multivariable analysis, adjuvant Se supplementation was not independently associated with favourable outcome (odds ratio = 1.19, 95% confidence interval = 0.86 to 1.65; P = 0.288).ConclusionsIn this retrospective analysis of a large cohort of surgical ICU patients with severe sepsis, adjuvant Se supplementation in the form of sodium selenite had no impact on in-hospital death rates after adjustment for confounders.

This study investigates the incidence of long-term consequences in survivors of critical illness 6 months after ICU care. A retrospective analysis of the risk factors was also completed. A mixed-method design was used. A qualitative design was used in the questionnaire study (phase 1), and a quantitative design was used for the retrospective study (phase 2). 116 patients were interviewed. Forty-eight patients (41.4%) reported at least one long-term consequence 6 months after ICU discharge. The most frequent consequences were anxiety (n = 33, 28.4%), depression (n = 32, 27.6%) and chronic pain (n = 24, 20.7%). The interview showed the concurrent caseness of PTSD, anxiety and depression in 14 (12.1%) patients. Observed risk factors were age > 60 years (OR = 2.65, IC = 1.23-5.69; p = 0.0119), trauma diagnosis (OR = 5.3, IC = 1.60-17.76; p = 0.0033), length of mechanical ventilation > 7 days (OR = 2.18, IC = 1-4.74; p = 0.0471) length of ICU stay > 10 days (OR = 2.47, IC = 1.16-5.26; p = 0.0185) and clinical conditions at the ICU admission. The quality of life score was lower if the respondent had long-term consequences. A high incidence of long-term consequences is found in survivors of critical illness. In future, studies that investigate interventions to prevent these issues after ICU care are need.

<h3>Introduction</h3> Patients with cirrhosis who are admitted to the ICU are considered to have a poor prognosis. Previous studies have sought to identify markers of high predictive value in patients who will not survive their critical care stay. These studies have focused upon early prognosis, rather than longer term survival. We sought to validate previously described outcome predictors and review long-term survival in a cohort of cirrhotic patients admitted to ICU. <h3>Method</h3> We performed a retrospective analysis of cirrhotic patients admitted to adult ICU, University Hosptial of Wales (Cardiff, UK) between 2009–14. Admission information was collated from the Intensive Care National Audit and Research Centre database. Child-Pugh, Model for End-stage Liver Disease-Na (MELD-Na) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were derived from data on admission to critical care. Statisical analyses were conducted with SPSS. <h3>Results</h3> One hundred and fifty one cirrhotics (2.8% of all critical care admissions) were admitted to the ICU with a mean age of 54 (range 22–80) and a male preponderance (65.6%). The predominant aetiology was alcoholic liver disease (ALD, 107/151, 70.9%). The reasons for ICU admission were variceal bleed 29.8%; sepsis 25.2%; decompensation 13.9%;non variceal bleed 5.3% and other 26%. ICU mortality was 43.7% for the 151 patients. Mean follow up after ICU discharge was 788 days (range 26–1722). Hyponatraemia (p &lt; 0.001), coagulopathy (p = 0.02), APACHE II (p = 0.004) and MELD-Na scores (p &lt; 0.0001) were significantly associated with mortality. Patients diagnosed as decompensation with no obvious underlining precipitant had a worse prognosis than those with precipitants (e.g. variceal bleeding, sepsis) which was maintained at follow up (p = 0.05). Child’s A, B and C stage patients had a mean overall survival of 1274, 976 and 690 days respectively (p = 0.01). Seventy-eight patients were discharge from hospital. Only 6 of these patients died, all with Child’s B liver disease. Only attending outpatient follow up clinic was associated with increased survival (p = 0.01 1373 v 1668 days). <h3>Conclusion</h3> Nearly half of all cirrhotics admitted to the ICU die before discharge, and two thirds of all patients have alcohol as an aetiological factor, emphasising the burden on our society. As expected, commonly used scoring systems predict short-term outcome, but often do not reflect long-term survival. Cirrhotics who survive the challenge of ICU admission seem to have quite marked physiological resilience and capacity for recovery with a good long term prognosis. Interestingly only patients with Child’s B cirrhosis continued to demonstrate a post-hospital discharge mortality, warranting further investigation for underlying reasons. <h3>Disclosure of interest</h3> None Declared.