Acute Physiologic Assessment And Chronic Health Evaluation Research Articles

Participant- and Disease-Related Factors as Independent Predictors of Treatment Outcomes in the RESTORE-IMI 2 Clinical Trial: A Multivariable Regression Analysis.

In the RESTORE-IMI 2 trial, imipenem/cilastatin/relebactam (IMI/REL) was noninferior to piperacillin/tazobactam in treating hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia. This post hoc analysis was conducted to determine independent predictors of efficacy outcomes in the RESTORE-IMI 2 trial, to assist in treatment decision making. A stepwise multivariable regression analysis was conducted to identify variables that were independently associated with day 28 all-cause mortality (ACM), favorable clinical response at early follow-up (EFU), and favorable microbiologic response at end of treatment (EOT). The analysis accounted for the number of baseline infecting pathogens and in vitro susceptibility to randomized treatment. Vasopressor use, renal impairment, bacteremia at baseline, and Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores ≥15 were associated with a greater risk of day 28 ACM. A favorable clinical response at EFU was associated with normal renal function, an APACHE II score <15, no vasopressor use, and no bacteremia at baseline. At EOT, a favorable microbiologic response was associated with IMI/REL treatment, normal renal function, no vasopressor use, nonventilated pneumonia at baseline, intensive care unit admission at randomization, monomicrobial infections at baseline, and absence of Acinetobacter calcoaceticus-baumannii complex at baseline. These factors remained significant after accounting for polymicrobial infection and in vitro susceptibility to assigned treatment. This analysis, which accounted for baseline pathogen susceptibility, validated well-recognized patient- and disease-related factors as independent predictors of clinical outcomes. These results lend further support to the noninferiority of IMI/REL to piperacillin/tazobactam and suggests that pathogen eradication may be more likely with IMI/REL. NCT02493764.

Variability in Early Surgery for Acute Cervical Spinal Cord Injury Patients: An Opportunity for Enhanced Care Delivery.

Data supporting the benefits of early surgical intervention in acute spinal cord injury (SCI) is growing. For early surgery to be accomplished, understanding the causes of variabilities that effect the timing of surgery is needed to achieve this goal. The purpose of this analysis is to determine factors that affect the timing of surgery for acute cervical SCI within the North American Clinical Trials Network (NACTN) for SCI registry. Patients in the NACTN SCI registry from 2005 to 2019 with a cervical SCI, excluding acute traumatic central cord syndrome, were analyzed for time elapsed from injury to arrival to the hospital, and time to surgery. Two categories were defined: 1) Early Arrival with Early Surgery (EAES) commenced within 24 h of injury, and 2) Early Arrival but Delayed Surgery (EADS), with surgery occurring between 24 to 72 h post-injury. Patients' demographic features, initial clinical evaluation, medical comorbidities, neurological status, surgical intervention, complications, and outcome data were correlated with respect to the two arrival groups. Of the 222 acute cervical SCI patients undergoing surgery, 163 (73.4%) were EAES, and 59 (26.6%) were EADS. There was no statistical difference in arrival time between the EAES and EADS groups. There was a statistical difference in the median arrival time to surgery between the EAES group (9 h) compared with the EADS group (31 h; p < 0.05). There was no statistical difference in race, sex, age, mechanism of injury, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores, or medical comorbidities between the two groups, but the EAES group did present with a significantly lower systolic blood pressure (p < 0.05). EADS patients were more likely to present as an American Spinal Injury Association Impairment Scale (AIS) D than EAES (p < 0.05). Early surgery was statistically more likely to occur if the injury occurred over the weekend (p < 0.05). There were variations in the rates of early surgery between the eight NACTN sites within the study, ranging from 57 to 100%. Of the 114 patients with 6-month outcome data, there was no significant change between the two groups regarding AIS grade change and motor/pin prick/light touch score recovery. A trend towards improved motor scores with early surgery was not statistically significant (p = 0.21). Although there is data that surgery within 24 h of injury improves outcomes and can be performed safely, there remain variations in care outside of clinical trials. In the present study of cervical SCI, NACTN achieved its goal of early surgery in 73.4% of patients from 2005-2019 who arrived within 24 h of their injury. Variability in achieving this goal was related to severity of neurological injury, the day of the week, and the treating NACTN center. Evaluating variations within our network improves understanding of potential systemic limitations and our decision-making process to accomplish the goal of early surgery.

The Attributable Factors That Increase the Likelihood of Central Line Associated Blood Stream Infection Related In-Hospital 30-Day Mortality.

The objective is to investigate the attributable factors associated with an increase in hospital 30-daymortality of central line bloodstream infection (CLABSI). A retrospective cohort study was conducted at King Saud University Medical City (KSUMC). The sample included adult patients who developed CLABSI between March 2016 and February 2018 after having a central line inserted at KSUMCin Riyadh, Saudi Arabia. A total of 283 patients were involved in the study. The 30-day mortality rate was 18.8%. Patients were more likely to die if they were in the intensive care unit (ICU) or required ICU admission after infection (p<0.001). This was also observed in patients who required inotropes or intubation before or after culture (p<0.001). There was a statistically significant difference of 6.60±5.62 in the mean score on the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II between before and after culture (p<0.001). The likelihood of death was significantly higher among patients with higher APACHE II scores before and after culture (p<0.001). The presence of CLABSI-related sequelae was not associated with increased mortality (p<0.595). The clinical characteristics of CLABSI patients are variable and can increase the risk of mortality or complicate the treatment course. Physicians should be aware of the significance of these factors as potential causes of increased mortality.

Evaluation of Dynamic Variation in Red Cell Distribution Width as a Septic Marker in Comparison with Procalcitonin Levels and Clinical Scores in Patients with Sepsis or Septic Shock: A Prospective Observational Study

BACKGROUND: Sepsis is a dysregulated host response to infection resulting in potentially life-threatening organ dysfunction. Elevation in red cell distribution width (RDW), a simple routinely done investigation, could be a prognostic marker in these patients. AIM: We performed this prospective observational study to assess role of dynamic variation of RDW in predicting 30-day mortality in patients with sepsis or septic shock presenting and getting admitted in intensive care unit (ICU) in Fayoum, Egypt. METHODS: Between January 2019 and January 2021, 150 patients with sepsis or septic shock at admission were prospectively evaluated for association between RDW value on admission, on day 4, on day 7, and 30-day mortality. To find out factors associated independently with 30-day mortality, we applied multivariate logistic regression analysis and used the analysis to develop nanogram for prediction of mortality on admission. RESULTS: Among 150 patients, 89 (59.3%) were male. Mean age of the patients was 59.6 ± 12.28 years. Regarding RDW on admission (RDW-0), the mean was 14.1 ± 1.9 while on day 4 (RDW-4), the mean was 14.5 ± 1.97, and on day 7 (RDW-7), the mean was 14.4 ± 2.03. Seventy-four (49.3%) patients died during the period of 30 days follow-up. Multiple logistic regression models for the parameters associated with the mortality outcome at admission were done, for age, higher age was associated with higher probability of mortality, OR = 1.07 (95% CI: 1.02, 1.13). Male sex was associated with lower probability of mortality as compared to females, OR = 0.02 (95% CI: 0.06, 0.80). Higher acute physiologic assessment and chronic health evaluation (APACHE) II score, RDW value, and procalcitonin level, all were associated with higher mortality probability. For APACHE II score, higher level was associated with higher odds of mortality, OR = 1.16. For RDW value on admission, higher value was associated with higher odds of mortality, OR = 1.66. For procalcitonin level at admission, higher level was associated with higher odds of mortality, OR = 1.54. Odds for mortality for those who showed any increase in RDW in day 4 as compared to day 0 are higher as compared to those who showed a decrease or no change in RDW, OR = 2.8, p-value = 0.007. CONCLUSIONS: We found that an increase in RDW value on admission and on day 4 is significantly associated with mortality. And that, an increase in RDW value from day 0 to day 4 is also significantly associated with mortality Therefore, a combination of baseline RDW value and an increase in serial RDW values can be a promising independent prognostic marker in patients with sepsis or septic shock.

Association of Serum Magnesium and Risk of Morbidity and Mortality in ICU-Admitted Patients Based on COVID-19 Infection Classification

Background: Magnesium (Mg) deficiency is a common clinical electrolyte abnormality in critically ill patients, which is related to higher mortality and is easily ignored. Objectives: We aimed to investigate the association of Mg levels with mortality and comorbidity in patients admitted to the intensive care unit (ICU) based on COVID-19 infection classification. Methods: A total of 69 patients admitted to the ICU of Shahid Mohammadi Hospital, Bandar Abbas, Iran, from June to December 2021were included in the present study. The serum Mg was measured in these patients. Data from sequential organ failure assessment (SOFA), acute physiologic assessment and chronic health evaluation (APACHE), ICU stay length, mechanical ventilation duration, mortality, and comorbidity were determined. Moreover, the COVID-19 infection was detected by PCR. Results: The mean ± SD age of patients (34.8% male) was 52.56 ± 16.43 years. Out of 69 patients, 18 (26.1%) died during hospitalization, and 24 (34.8%) required mechanical ventilation. The prevalence of COVID-19 was 39.1% (27 patients). Our results showed no difference in serum Mg between patients based on mortality and comorbidity status. However, the Mg level of patients with kidney failure was significantly higher than patients without kidney failure (P &lt; 0.05). Based on the COVID-19 classification, there was only a positive correlation between hypomagnesemia and the length of ICU hospitalization in patients without COVID-19 (P &lt; 0.05). Conclusions: Our findings showed no difference in the Mg levels of patients based on mortality status. Patients with kidney failure had higher serum Mg than those without kidney failure. Furthermore, our results showed no difference in the Mg levels of critically ill patients based on COVID-19 infection status.

Investigation of the changes in the general characteristics of COVID19 patients with the vaccination program

Since the onset of the Coronavirus Disease 2019 (COVID-19) pandemic, many vaccine research studies have started. Changes in the demographic characteristics of the patients hospitalized from the emergency room to the intensive care unit due to COVID-19 has caught our attention since the vaccination program began in Turkey. The purpose of this study is to investigate whether our investigation is scientifically valid and meaningful. Thus, it will be helpful to investigate the effect of priority ordering in vaccination programs in future pandemics. Demographic characteristics and hospitalization processes of patients hospitalized in the intensive care unit before and after vaccination were compared. For comparison, Charlson Comorbidity Index (CCI) and Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) scores, as well as intensive care unit duration of stay and mortality were used. While age [mean (SD); 70,8 (12,2) vs 66,2 (15,2), p=0,032] and duration of intensive care stay [day; mean (SD); 6,4 (6,3) vs 9,4 (7,4); p&lt;0,001] increased in the post-vaccination group, a statistically significant decrease was observed in APACHE [mean (SD); 26,9 (9,2) vs 20,9 (9,0); p=0,008] and CCI scores [mean (SD); 4,3 (2,2) vs 3,6 (2,7); p&lt;0,001]. Regulating the priorities of those to be vaccinated causes rapid changes in the patient population. For this reason, vaccination of vulnerable groups will contribute to the operation of the health system properly.

PGI score: prospective validation and correlation with SOFA, SAPS-II, and APACHE-II scores for predicting outcomes in acute aluminum phosphide poisoning.

We recently derived a simplified 3-point PGI score (representing blood pH<7.25, Glasgow coma scale [GCS] score<13, and impaired systolic blood pressure [SBP]<90mm Hg), which accurately predicted in-hospital case fatality ratio (CFR) in acute aluminum phosphide poisoning. The present study aimed to validate the PGI score and compare it with Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score, Sequential Organ Failure Assessment score (SOFA), and Simplified Acute Physiology Score (SAPS) II scores. We performed a prospective cohort study in adult patients with aluminum phosphide ingestion admitted in PGIMER, Chandigarh (India), from April 2013 to August 2014. A univariant analysis detected the association of various baseline variables with CFR. Correlation of the PGI score with SOFA, SAPS-II, and APACHE-II scores was performed using Spearman's correlation (rs , range -1 to +1) and scatter plots. Seventy-six patients were enrolled (mean age, 28.3years; 41 males). CFR was 60.5%. PGI score variables-pH, GCS, and impaired SBP predicted CFR (P-value <0.001). Among patients with a total PGI score of 3 or 2, 100% died, compared with 50% in score 1 and 10.7% in score 0. Baseline PGI, SOFA, SAPS-II, and APACHE-II scores predicted CFR (P-value <0.001). There was a positive correlation between the PGI score and SOFA score (rs , 0.855), SAPS-II score (rs , 0.861), and APACHE-II score (rs , 0.883). The P-value for all rs values was <0.001. The PGI score is a validated toxidrome-specific and simplified risk-stratification tool. Validation in other populations is warranted to confirm its routine use.

Effect of traditional Chinese medicine on serum inflammation and efficacy in patients with sepsis: a systematic review and meta-analysis.

Sepsis is a systemic infectious inflammatory response syndrome, which can release a large number of inflammatory mediators in serum, resulting in organ dysfunction. This study conducted a systematic review and meta-analysis of the reports of traditional Chinese medicine (TCM) in the treatment of sepsis in recent years, providing evidence for clinical diagnosis and treatment. The databases of PubMed, Chinese Medical Literature (CBM), China National Knowledge Infrastructure (CNKI), Medline, and Web of Science were searched for clinical randomized controlled trials (RCTs) related to "Chinese traditional medicine" and "Sepsis" published from January 2015 to August 2021. After screening qualified articles, RevMan 5.4 software was used to evaluate the bias of included studies and perform meta-analysis. Finally, 8 articles were retrieved and screened, and a total of 862 patients entered the study. The results of meta-analysis showed that serum interleukin-6 (IL-6) levels were lower in sepsis patients after TCM treatment [mean difference (MD) =-20.70; 95% confidence interval (CI): -33.68 to -7.73; P=0.002]; tumor necrosis factor-α (TNF-α) levels were lower (MD =-4.17; 95% CI: -5.98 to -2.37; P<0.00001); acute physiological assessment and chronic health evaluation (APACHE) II scores were lower (MD =-2.92; 95% CI: -3.50 to -2.35; P<0.00001); mortality was lower [odds ratio (OR) =0.49; 95% CI: 0.33 to 0.74; P=0.0006]; and effective rate was higher (OR =3.43; 95% CI: 1.72 to 6.85; P=0.0005). On the basis of traditional western medicine treatment of sepsis, the addition of TCM treatment can effectively reduce the serum inflammatory response, improve the patient's immunity, and improve treatment efficacy.

The association between serum levels of micronutrients and the severity of disease in patients with COVID-19

ObjectivesThis study aimed to compare the serum level of micronutrients with normal amounts, and assess their association with the severity of disease and inflammatory cytokines in patients with coronavirus disease 2019 (COVID-19). MethodsThe present cross-sectional study included 60 patients admitted to the intensive care unit with COVID-19. We recorded data on demographic characteristics, anthropometric information, and medical history. Serum levels of inflammatory markers (erythrocyte sedimentation rate, C-reactive protein, interferon-gamma, tumor necrosis factor-alpha, interleukin-6), vitamins (A, B9, B12, C, D, E), and minerals (magnesium, zinc, iron) were measured. A radiologist assessed the severity of lung involvement according to patient computed tomography scans. The severity of illness was evaluated with the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) score, oxygen saturation, and body temperature. Independent associations among the serum levels of micronutrients with the severity of COVID-19 were measured. ResultsMedian patient age was 53.50 years (interquartile range, 12.75 years). Except for vitamin A and zinc, serum levels of other micronutrients were lower than the minimum normal. Patients with APACHE score ≥25 had a higher body mass index (P = 0.044), body temperature (P = 0.003), erythrocyte sedimentation rate (P = 0.008), C-reactive protein (P = 0.003), and lower oxygen saturation (P = 0.005), serum levels of vitamin D (P = < 0.001), and zinc (P = < 0.001) compared with patients with APACHE score <25. We found that lower serum levels of vitamin D, magnesium, and zinc were significantly and independently associated with higher APACHE scores (P = 0.001, 0.028, and < 0.001, respectively) and higher lung involvement (P = 0.002, 0.045, and < 0.001, respectively). ConclusionsLower serum levels of vitamin D, zinc, and magnesium were involved in severe COVID-19.

Intradialytic Hypotension in Critically Ill Patients on Hemodialysis With A-Line versus B-Line Pattern on Lung Ultrasonography

Intradialytic Hypotension in Critically Ill Patients on Hemodialysis With A-Line versus B-Line Pattern on Lung Ultrasonography

A Retrospective Review of Outcomes in Intensive Care Unit Patients Infected With SARS-Cov2 in Correlation to Admission Acute Physiologic Assessment and Chronic Health Evaluation II Scores.

IntroductionCoronavirus disease 2019 (COVID-19) has emerged as a global pandemic that has placed an unprecedented burden on intensive care services worldwide. Identification of a reliable risk-stratification tool for COVID-19 patients is necessary for appropriate resource allocation, selection of clinical management pathways, and guidance of goals of care conversations with families and caregivers in the critical care setting. The Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scoring system is one of several predictive models used to classify illness severity and estimate mortality risk on admission to the intensive care unit (ICU). Our retrospective study sought to evaluate the prognostic ability of the APACHE II score in COVID-19 patients according to endpoints of mortality and length of stay (LOS) as well as unfavorable clinical outcomes, including development of acute renal failure (ARF) requiring renal replacement therapy (RRT) and acute venous thromboembolic events (VTE).MethodsThis multicenter retrospective cohort study evaluated a randomized sample of 3,102 patients with confirmed COVID-19 disease admitted to the ICU from January 2020 to May 2020. A total of 395 patients with complete data points for appropriate APACHE II score calculation, absence of the preexisting comorbidities end-stage renal disease, and history of VTE were included. Linear and logistic regression models were employed to evaluate primary outcomes of mortality and LOS as well as secondary outcomes of VTE and ARF requiring continuous renal replacement therapy (CRRT) or hemodialysis (HD).Key resultsAmong the 395 patients enrolled, total percent mortality and mean LOS were 37.0% and 12.92 days, respectively. Primary outcome analysis revealed a statistically significant increase in odds of mortality as well as in mean LOS with every additional point increase in APACHE II score from a baseline of zero. Specifically, for every point increase in the APACHE II score, odds of mortality increased by 12% (p value < 0.001), and average LOS increased by 0.2 days (p value < 0.001). In our secondary outcome analysis, 14.43% and 62.2% of the total sample population developed ARF requiring RRT and VTE, respectively. For every additional point increase in APACHE II score from a baseline of zero, odds of requiring CRRT or HD increased by 10% on average (95% CI (1.06, 1.15); p value < 0.001). Similarly, for every additional point increase in the APACHE II score from a baseline of zero, there was a corresponding increase in odds of VTE by 19% (95% CI (1.14, 1.24); p value < 0.001).ConclusionsThe APACHE II score is an effective predictive model of in-hospital mortality and unfavorable clinical outcomes, including prolonged LOS, ARF requiring CRRT or HD, and development of VTE. As therapeutic interventions for COVID-19 evolve, application of this risk-stratification tool may guide clinical management decisions in the critical care setting.

The Prevalence, Risk Factors, and Prognosis of Acute Kidney Injury After Lung Transplantation: A Single-Center Cohort Study in China

PurposeThe aim of this study is to evaluate the incidence, risk factors, and prognosis of acute kidney injury (AKI) after lung transplantation (LTx). MethodsRecords of patients who underwent LTx in a single center were retrospectively reviewed. The prevalence of post-transplant AKI, the use of continuous renal replacement therapy (CRRT), and the risk factors for AKI were investigated. The effects of AKI and CRRT on short-term outcomes and long-term survival were measured. ResultsThis study included 148 patients, 67 of which developed postoperative AKI. Of these, 31 patients underwent CRRT; the percentage of cases with no AKI was 6.2%, and the percentage of cases with stage 1, 2, and 3 who used CRRT was 0%, 10%, and 86.2%, respectively. Patients with AKI had significantly higher intensive care unit mortality and in-hospital mortality. The 1-year post-LTx survival rate of patients with AKI was 47.8%, significantly lower than those without AKI (74.1%). There was no difference in 1-year survival rate of those with stage 1 and stage 2 AKI, but patients with stage 3 AKI showed the worst survival. Patients who underwent CRRT had an inferior survival outcome (9.7% vs 76.1%, P < .05). We found that higher acute physiologic assessment and chronic health evaluation (APACHE) II scores (odds ratio [OR] 1.082, P = .009) and higher intraoperative fluid balance (OR 1.001, P = .012) were independent risk factors, and female sex (OR 2.539) and pulmonary hypertension (OR 2.869) were potential risk factors for post-LTx AKI. A prediction model integration of the above factors showed a good concordance with actual risks and had a concordance index (C-index) of 0.76 (95% confidence interval [CI], 0.66-0.87). ConclusionSevere AKI requiring CRRT had a negative impact on the short-term and long-term outcomes of patients.

A Racially Unbiased, Machine Learning Approach to Prediction of Mortality: Algorithm Development Study.

BackgroundRacial disparities in health care are well documented in the United States. As machine learning methods become more common in health care settings, it is important to ensure that these methods do not contribute to racial disparities through biased predictions or differential accuracy across racial groups.ObjectiveThe goal of the research was to assess a machine learning algorithm intentionally developed to minimize bias in in-hospital mortality predictions between white and nonwhite patient groups.MethodsBias was minimized through preprocessing of algorithm training data. We performed a retrospective analysis of electronic health record data from patients admitted to the intensive care unit (ICU) at a large academic health center between 2001 and 2012, drawing data from the Medical Information Mart for Intensive Care–III database. Patients were included if they had at least 10 hours of available measurements after ICU admission, had at least one of every measurement used for model prediction, and had recorded race/ethnicity data. Bias was assessed through the equal opportunity difference. Model performance in terms of bias and accuracy was compared with the Modified Early Warning Score (MEWS), the Simplified Acute Physiology Score II (SAPS II), and the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE).ResultsThe machine learning algorithm was found to be more accurate than all comparators, with a higher sensitivity, specificity, and area under the receiver operating characteristic. The machine learning algorithm was found to be unbiased (equal opportunity difference 0.016, P=.20). APACHE was also found to be unbiased (equal opportunity difference 0.019, P=.11), while SAPS II and MEWS were found to have significant bias (equal opportunity difference 0.038, P=.006 and equal opportunity difference 0.074, P<.001, respectively).ConclusionsThis study indicates there may be significant racial bias in commonly used severity scoring systems and that machine learning algorithms may reduce bias while improving on the accuracy of these methods.

Clinical outcomes of difficult-to-wean patients with ventilator dependency at intensive care unit discharge.

BackgroundVentilator-dependent patients in the intensive care unit (ICU) who are difficult to wean from invasive mechanical ventilation (IMV) have been increasing in number. However, data on the clinical outcomes of difficult-to-wean patients are lacking. We aimed to evaluate clinical outcomes in patients discharged from the ICU with tracheostomy and ventilator dependency.MethodsWe retrospectively investigated clinical course and survival in patients requiring home mechanical ventilation (HMV) with a tracheostomy and difficulty weaning from IMV during medical ICU admission from September 2013 through August 2016 at Severance Hospital, Yonsei University, Seoul, Korea.ResultsOf 84 difficult-to-wean patients who were started on HMV in the medical ICU, 72 survived, were discharged from the ICU, and were included in this analysis. HMV was initiated after a median of 23 days of IMV, and the successful weaning rate was 46% (n=33). In-hospital mortality rate was significantly lower in the successfully weaned group than the unsuccessfully weaned group (0% vs. 23.1%, respectively; P=0.010). Weaning rates were similar according to primary diagnosis, but high body mass index (BMI), low Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score at ICU admission, and absence of neuromuscular disease were associated with weaning success. After a median follow-up of 4.6 months (range, 1–27 months) for survivors, 3-month (n=64) and 6-month (n=59) survival rates were 82.5% and 72.2%, respectively. Survival rates were higher in the successfully weaned group than the unsuccessfully weaned group at 3 months (96.4% vs. 69.0%; P=0.017) and 6 months (84.0% vs. 62.1%; P=0.136) following ICU discharge.ConclusionsIn summary, 46% of patients who started HMV were successfully weaned from the ventilator in general wards. High BMI, low APACHE II score, and absence of neuromuscular disease were factors associated with weaning success.

Nutritional Assessment in the Critically Ill Patients

Background: Malnutrition is a prevalent complication among critically ill patients. It has very detrimental effects on the patients' clinical course. This study aimed to investigate the impact of nutrition in the intensive care unit (ICU) patients.&#x0D; Methods: In this epidemiologic-analytic study conducted in the surgical ICU of Imam Khomeini hospital, Ahvaz, Iran, 34 patients were selected and divided into two groups. The first group of patients received the appropriate nutrition. The second group received an inappropriate diet, and the nutritional risk was evaluated according to the modified- Nutrition Risk in Critically ill (m-NUTRIC) score. The energy was calculated by using 25 Kcal/kg, also the two groups were compared in terms of ICU mortality, ICU stays, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II Scoring, and the Sequential Organ Failure Assessment (SOFA) Score.&#x0D; Results: Baseline data, such as APACHE II score and mean age, except sex, were not significantly different between the two groups. In this study, results were toward shorter ICU stay, less mortality, and better SOFA score in the group receiving appropriate nutrition compared to the other group. However, due to the low number of patients, no significant differences were observed in the two groups.&#x0D; Conclusion: Our data suggest that nutritional support should be considered as an essential part of the medication during critical illness.

Results from the first audit of an intensive care unit in Botswana.

Botswana is an economically stable middle-income country with a developing health system and a large HIV and infectious disease burden. Princess Marina Hospital (PMH) is the largest referral and teaching hospital with a mixed eight-bed intensive care unit (ICU). To conduct an audit of PMH ICU in order to investigate major admission categories and quantify morbidity and mortality figures using a validated scoring system for quality improvement, education and planning purposes. PMH medical records and laboratory data were accessed to record demographics, referral patterns, diagnoses, HIV status, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores and mortality rates. A total of 182 patients >14 years of age were enrolled over a 12-month period from April 2017 - March 2018. Patient's mean age was 42.9 years, males represented 56.6% of the study population and surgical conditions accounted for 46% of diagnostic categories. Sixty percent of the patients were HIV-negative and 12% had no HIV status recorded. The mean APACHE II score was 25 and the mean length of stay in ICU was 10.3 days. Higher APACHE II scores were associated with higher mortality regardless of HIV status. The overall mortality was 42.8% and there was no difference in mortality rates in ICU or at 30 days between HIV-positive and HIV-negative ICU patient groups. The PMH ICU population is young with a high mean APACHE II score, significant surgical and HIV burdens and a high mortality rate. PMH ICU has significant logistical challenges making comparison with international ICUs challenging, and further research is warranted. This study is the first published audit for an intensive care unit in Botswana. The findings are especially relevant for the development of critical care capacity in the country during the current COVID-19 pandemic. We advocate for the establishment of an ICU registry in the country to allow ongoing accurate research in the field of critical care medicine and to improve healthcare for all critically ill patients in Botswana.

Colistin Plus Carbapenem versus Colistin Monotherapy in the Treatment of Carbapenem-Resistant Acinetobacter baumannii Pneumonia.

PurposeColistin alone may not be sufficient for treating carbapenem-resistant Acinetobacter baumannii (CRAB); thus, efforts are needed to increase treatment success rates. We compared the effects of colistin plus carbapenem therapy versus colistin monotherapy in treating pneumonia caused by CRAB and attempted to identify specific populations or factors that could benefit from combination therapy.MethodsWe retrospectively collected data on cases of CRAB pneumonia. The patients were divided into colistin plus carbapenem therapy and colistin monotherapy groups. The primary outcome was 14-day mortality. The secondary outcomes were in-hospital mortality, clinical improvement at days 2 and 14, and microbiological improvement at day 14.ResultsOf 160 cases meeting criteria for CRAB pneumonia, 83 (52%) and 77 (48.0%) were treated with carbapenem combination therapy or colistin monotherapy, respectively. Among these patients, 50 (63.3%) in the combination group and 27 (39.7%) in the monotherapy group had Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores >24 points (p=0.010). Overall, there was no significant difference in 14-day mortality between the combination and monotherapy groups (24.1% vs 20.8%, p=0.616). Clinical improvement and sputum-negative conversion also showed no significant difference. After adjusting for disease severity according to APACHE II score, the 14-day mortality was significantly lower in the combination group than in the monotherapy group among patients with APACHE II scores of 25–29 points (9.1% vs 53.8%, P=0.020).ConclusionDespite more severe conditions, compared with colistin monotherapy, colistin plus carbapenem combination therapy showed equivalent primary mortality outcome in treating CRAB pneumonia. Combination therapy was more effective in patients with APACHE II score ranging from 25 to 29 points.

520. The Clinical Profile and Outcomes of Patients given Intravenous Colistin for Multidrug-Resistant Gram-negative Infections in a Philippine Tertiary Hospital

BackgroundColistimethate sodium (colistin) is used to treat multi-drug-resistant Gram-negative infections. We describe the profile and outcomes of patients given colistin in a tertiary level government hospital.MethodsWe performed a retrospective cross-sectional study of patients from the Philippine General Hospital given intravenous colistin between January 2015 to June 2018. Adult patients who received colistin for at least 24 hours and not on dialysis were included. Clinical success was defined as a composite of hemodynamic stability, stable quick Sequential Organ Failure Assessment score (qSOFA), and microbiological cure. Overall in-hospital mortality was recorded.ResultsWe included 250 patients during the study period. The median age was 55 (19–91) years, 55.6% (139/250) were male, and 49.2% (123/250) were admitted in the intensive care unit (ICU). 77.2% (193/250) had at least one comorbidity, with solid-organ malignancy (27.6%, 69/250) being the most common. Most patients had at least one invasive device, commonly a nasogastric tube (64.4%, 161/250) or mechanical ventilator (63.2%, 150/250). There was an increase in Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score, qSOFA, and septic shock from baseline to 24 hours prior to colistin use (Table 1). The most common site of infection was the respiratory tract (90.8%, 227/250). Majority of patients (78.8%, 197/250) had Acinetobacter baumannii infection of which 79.9% were extensively drug-resistant (XDR), susceptible only to colistin and amikacin or minocycline. Colistin was given for a mean of 12 (2- 43) days, concomitant with meropenem in 96.4% (241/250). Most patients received piperacillin–tazobactam (59%, 142/250) and/or meropenem (58%, 138/250) within the same admission. Nephrotoxicity (30.8%, 77/250) was the most frequent adverse effect (Table 2). Renal replacement therapy was needed in 6% (15/250) patients. Clinical success was seen in 61.2% (153/250) patients and overall mortality was 41.6% (104/250).ConclusionColistin was frequently used in combination with a carbapenem for treatment of XDR-related respiratory infection or septic shock. Nephrotoxicity was a common adverse effect. The clinical success rate was modest and overall mortality was high. Disclosures All authors: No reported disclosures.

CORRELATION OF RADIOGRAPHIC ASSESSMENT OF THE QUANTITY OF LUNG EDEMA (RALE) SCORES AND ARDS SEVERITY

SESSION TITLE: ARDS: Fine-tuning Details in Management SESSION TYPE: Original Investigations PRESENTED ON: 10/21/2019 1:30 PM - 2:30 PM PURPOSE: Our primary outcome was to determine if a correlation exists between RALE scores and ARDS severity as measured by the time to decreased FiO2 requirement less than 0.4. We also evaluated if RALE scores were correlated with brain natriuretic peptide (BNP), Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) score, and in-hospital mortality. METHODS: We performed a retrospective chart review of all admissions to a 16-bed medical intensive care unit (MICU) in an urban community-academic hospital from May 2016 to January 2018. We identified 47 patients intubated for acute hypoxic respiratory failure, and who met ARDS criteria based on chest x-ray findings and pulse oximetric saturation Spo2/Fio2 (SF) ratio. Data collected for these patients included: Ventilator settings, BNP, APACHE score, time to decreased FiO2 RESULTS: 36/47 (76.5%) of the patients had a high RALE score (>23). In pts with RALE score >23, the average time to decrease FiO2 23 patients had a high apache score (>23) and 13/32 (40%) had a high BNP (>583). The death rate in patients with higher RALE Score was 17/36 (47%); of these 7/17 (41%) were associated to an elevated BNP and 6/17 (35%) had a higher APACHE. Only 3/17 (17.6%) deaths had both elevated BNP and APACHE score. Contrarily, 11/47 (23.5%) of our ARDS patients had a low RALE score (23) and 1/6 (16.7%) had a high BNP (>583). The death rate in patients with lower RALE Score was 6/11 (54.5%); of these 1/6 (16.7%) were associated to an elevated BNP and 6/6 (100%) had a higher APACHE. Only 1/6 (16.7) deaths had both elevated BNP and APACHE score. CONCLUSIONS: Higher RALE scores did not correlate with worse clinical outcomes in our patient population compared to those with a lower RALE score. Lower RALE scores seem to correlate with worse characteristics and clinical outcomes including higher BNP, APACHE and death rates. These finding suggest that RALE score alone does not determine ARDS severity. Given our ARDS population also had elevated BNPs it would be worthwhile extending the study to include the role of diuresis in these patients. CLINICAL IMPLICATIONS: Though effective in creating an objective measure for ARDS severity, the RALE score alone doesn’t correlate with acuity of patients with ARDS and their clinical outcomes. A larger patient population would be needed to further analyze the relation between RALE scores and other patient characteristics that increase ARDS severity. DISCLOSURES: No relevant relationships by John Kileci, source=Web Response No relevant relationships by Young Im Lee, source=Web Response No relevant relationships by Natalie Marte, source=Web Response No relevant relationships by Martha Catalina Morales Alvarez, source=Web Response No relevant relationships by Risako Shirane, source=Web Response No relevant relationships by M. Faisal Siddiqi, source=Web Response

Survival prediction in intensive-care units based on aggregation of long-term disease history and acute physiology: a retrospective study of the Danish National Patient Registry and electronic patient records

Intensive-care units (ICUs) treat the most critically ill patients, which is complicated by the heterogeneity of the diseases that they encounter. Severity scores based mainly on acute physiology measures collected at ICU admission are used to predict mortality, but are non-specific, and predictions for individual patients can be inaccurate. We investigated whether inclusion of long-term disease history before ICU admission improves mortality predictions. Registry data for long-term disease histories for more than 230 000 Danish ICU patients were used in a neural network to develop an ICU mortality prediction model. Long-term disease histories and acute physiology measures were aggregated to predict mortality risk for patients for whom both registry and ICU electronic patient record data were available. We compared mortality predictions with admission scores on the Simplified Acute Physiology Score (SAPS) II, the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II, and the best available multimorbidity score, the Multimorbidity Index. An external validation set from an additional hospital was acquired after model construction to confirm the validity of our model. During initial model development data were split into a training set (85%) and an independent test set (15%), and a five-fold cross-validation was done during training to avoid overfitting. Neural networks were trained for datasets with disease history of 1 month, 3 months, 6 months, 1 year, 2·5 years, 5 years, 7·5 years, 10 years, and 23 years before ICU admission. Mortality predictions with a model based solely on disease history outperformed the Multimorbidity Index (Matthews correlation coefficient 0·265 vs 0·065), and performed similarly to SAPS II and APACHE II (Matthews correlation coefficient with disease history, age, and sex 0·326 vs 0·347 and 0·300 for SAPS II and APACHE II, respectively). Diagnoses up to 10 years before ICU admission affected current mortality prediction. Aggregation of previous disease history and acute physiology measures in a neural network yielded the most precise predictions of in-hospital mortality (Matthews correlation coefficient 0·391 for in-hospital mortality compared with 0·347 with SAPS II and 0·300 with APACHE II). These results for the aggregated model were validated in an external independent dataset of 1528 patients (Matthews correlation coefficient for prediction of in-hospital mortality 0·341). Longitudinal disease-spectrum-wide data available before ICU admission are useful for mortality prediction. Disease history can be used to differentiate mortality risk between patients with similar vital signs with more precision than SAPS II and APACHE II scores. Machine learning models can be deconvoluted to generate novel understandings of how ICU patient features from long-term and short-term events interact with each other. Explainable machine learning models are key in clinical settings, and our results emphasise how to progress towards the transformation of advanced models into actionable, transparent, and trustworthy clinical tools. Novo Nordisk Foundation and Innovation Fund Denmark.