Medical Intensive Care Unit Admission Research Articles

Effect of Boarding on Mortality in ICUs.

Hospitals use a variety of strategies to maximize the availability of limited ICU beds. Boarding, which involves assigning patients to an open bed in a different subspecialty ICU, is one such practice employed when ICU occupancy levels are high, and beds in a particular unit are unavailable. Boarding disrupts the normal geographic colocation of patients and care teams, exposing patients to nursing staff with different training and expertise to those caring for nonboarders. We analyzed whether medical ICU patients boarding in alternative specialty ICUs are at increased risk of mortality. Retrospective cohort study using an instrumental variable analysis to control for unmeasured confounding. A semiparametric bivariate probit estimation strategy was employed for the instrumental model. Propensity score matching and standard logistic regression (generalized linear modeling) were used as robustness checks. The medical ICU of a tertiary care nonprofit hospital in the United States between 2002 and 2012. All medical ICU admissions during the specified time period. None. The study population consisted of 8,429 patients of whom 1,871 were boarders. The instrumental variable model demonstrated a relative risk of 1.18 (95% CI, 1.01-1.38) for ICU stay mortality for boarders. The relative risk of in-hospital mortality among boarders was 1.22 (95% CI, 1.00-1.49). GLM and propensity score matching without use of the instrument yielded similar estimates. Instrumental variable estimates are for marginal patients, whereas generalized linear modeling and propensity score matching yield population average effects. Mortality increased with boarding of critically ill patients. Further research is needed to identify safer practices for managing patients during periods of high ICU occupancy.

Home return following invasive mechanical ventilation for the oldest-old patients in medical intensive care units from two US hospitals.

Background:The aging of the US population has been associated with an increase in intensive care unit (ICU) utilization and correspondingly, invasive mechanical ventilation (IMV) among the oldest-old (age ≥80 years). While previous studies have examined ICU and IMV outcomes in the elderly, very few have focused on patient-centered outcomes, specifically home return, in the oldest-old. We investigated the rate of immediate home return following IMV in the medical ICU in previously home-dwelling oldest-old patients relative to that of a comparison group of 50–70-year olds.Methods:Data were extracted retrospectively from patient records at Elmhurst Hospital Center in Elmhurst, NY, USA, encompassing the period from January 2009 to May 2014 and Jacobi Medical Center in the Bronx, NY, USA, from January 2010 to March 2014. Medical ICU admissions within those date ranges were screened for possible inclusion into one of two study groups based on age: ≥80 years old and 50–70 years old. The primary end point was hospital discharge: home return versus no home return (death or nonhome discharge). Cox proportional hazards’ regression models were used to estimate crude and multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for failure to return home.Results:A total of 375 patients were included in the analysis: 279 (74%) patients aged 50–70 years and 96 (26%) patients aged ≥80 years. Compared to 50–70-year olds, being ≥80 years old was associated with a nearly two-fold greater risk of no home return: adjusted HR: 1.96; 95% CI 1.43–2.67. The oldest-old was at significantly increased risk of both being discharged to a skilled nursing facility or subacute rehabilitation (adjusted HR: 2.19; 95% CI 1.33–3.59) as well as of dying in the hospital (adjusted HR: 1.81; 95% CI 1.21–2.71).Conclusion:Previously home-dwelling oldest-old are at significantly increased risk of failing to return home immediately following medical ICU admission with IMV as compared to patients aged 50–70 years. These results can help medical ICU staff establish appropriate expectations when addressing the families of their oldest patients. Further studies are needed to evaluate the potential for delayed home return among the oldest old and to assess the ability of frailty indices to predict home return within this ICU population.

Metabolomic state as early indicator of responsiveness to therapy in the acute phase of septic shock

Medical patients whose care needs exceed what is feasible on a general ward, but who do not clearly require critical care, may be admitted to an intermediate care unit (IMCU). Some IMCU patients deteriorate and require medical intensive care unit (MICU) admission. In 2012, staff in the Johns Hopkins IMCU expressed concern that patient acuity and the threshold for MICU admission were too high. Further, shared triage decision-making between residents and supervising physicians did not consistently occur.To improve our triage process, we used a 4Es quality improvement framework (engage, educate, execute, evaluate) to (1) educate residents and fellows regarding principles of triage and (2) facilitate real-time communication between MICU residents conducting triage and supervising physicians.Among patients transferred from the IMCU to the MICU during baseline (n = 83;July–December 2012) and intervention phases (n = 94;July–December 2013), unadjusted mortality decreased from 34% to 21% (p = 0.06). After adjusting for severity of illness, admitting diagnosis, and bed availability, the odds of death were lower during the intervention vs. baseline phase (OR 0.33; 95%CI 0.11–0.98).Using a structured quality improvement process targeting triage education and increased resident/supervisor communication, we demonstrated reduced mortality among patients transferred from the IMCU to the MICU.

Heart Failure Study: Profile of Heart Failure Admissions in Medical Intensive Care Unit

Heart failure (HF) is a major cause of morbidity and mortality all over the world. In developed countries because of aging population and increased prevalence of coronary artery disease, heart failure has attained epidemic proportions, whereas, in developing countries like Nepal, rheumatic heart dissease is still the commonest cause of HF admission in medical intensive care unit (MICU). A retrospective study analysing registered data of HF admissions in MICU of Shahid Gangalal National Heart Centre (SGNHC) from August 2002 to OCtober 2008. Among these, 1771 patients were admitted for management of HF and were included in this study. Mean age was 45.07 Å} 35.09 (ranges from 11 years to 95 years). 836 (47%) were male and 935 (53%) were female. Rheumatic heart disease causing valvular cardiac lesion leading to HF was found in 791 (45%) patients. Dilated cardiomyopathy in 424 (24%), Ischemic heart disease in 378 (1%), hypertensive heart failure in 101 (6%) and HG due to congenital heart disease was found in 43 (2%) patients, Though, HF due to COPD / Cor-pulmonale is usually discouraged to be admitted in this heart centre, still 34(2%) patients were admitted for the management of HF due to COPD/cor-pulmonale. Rheumatic heart disease causing valvular cardiac lesion leading to HF admission was still the commonest cause of HF admission in MICU in our heart centre. Despite ACC/AHA guideline suggesting use of beta-blocking agent in patients with heart failure, only 22% of our patients received that agent. Thus, many patients were not being managed fully in accordance with international evidence based guidelines.

Pre-discharge rehabilitation after hip surgery reduces 30-day readmissions in older adults: National Health Insurance Service–Senior Cohort (2007–2012)

BackgroundRehabilitation programs before and after hip surgery can shorten the length of hospital stay, reduce the incidence of complications, and reduce the readmission rate after surgery in older adults aged 65years or over. The present study aimed to investigate the status of readmissions within 30days after discharge and related factors in elderly people through the big data analysis using the sample data from the National Health Insurance Service-Senior Cohort (NHIS-SC). MethodThe subjects of the present study were patients aged 65years or older who underwent hip surgery between 2007 and 2012. The subjects undergoing hip surgery included those who underwent at least one surgery of the following during the period: replacement arthroplasty, revision arthroplasty, arthrodesis, internal fixation, reduction of fractured extremity and internal fixation. Each variable was selected for sociodemographic characteristics and clinical features of the subjects, and the characteristics of medical institutions according to 30-day readmission. ResultsAmong 9008 study participants, 1628 (18.1%) were readmitted within 30days. Lower readmission rate was associated with longer hospital stay, greater number of hospital beds, and rehabilitation before discharge; whereas a higher rate was associated with provincially located hospitals, getting of medical aid, accompanying fractures, ICU admission, and comorbidities. ConclusionsPre-discharge rehabilitation in patients aged ≥65years who underwent hip surgery can reduce readmissions, and efforts to increase daily living functions such as muscle strength and walking ability are very important.

Intermediate care to intensive care triage: A quality improvement project to reduce mortality

PurposeMedical patients whose care needs exceed what is feasible on a general ward, but who do not clearly require critical care, may be admitted to an intermediate care unit (IMCU). Some IMCU patients deteriorate and require medical intensive care unit (MICU) admission. In 2012, staff in the Johns Hopkins IMCU expressed concern that patient acuity and the threshold for MICU admission were too high. Further, shared triage decision-making between residents and supervising physicians did not consistently occur. MethodsTo improve our triage process, we used a 4Es quality improvement framework (engage, educate, execute, evaluate) to (1) educate residents and fellows regarding principles of triage and (2) facilitate real-time communication between MICU residents conducting triage and supervising physicians. ResultsAmong patients transferred from the IMCU to the MICU during baseline (n=83;July–December 2012) and intervention phases (n=94;July–December 2013), unadjusted mortality decreased from 34% to 21% (p=0.06). After adjusting for severity of illness, admitting diagnosis, and bed availability, the odds of death were lower during the intervention vs. baseline phase (OR 0.33; 95%CI 0.11–0.98). ConclusionsUsing a structured quality improvement process targeting triage education and increased resident/supervisor communication, we demonstrated reduced mortality among patients transferred from the IMCU to the MICU.

Race, Ethnicity, Health Insurance, and Mortality in Older Survivors of Critical Illness.

To determine whether minority race or ethnicity is associated with mortality and mediated by health insurance coverage among older (≥ 65 yr old) survivors of critical illness. A retrospective cohort study. Two New York City academic medical centers. A total of 1,947 consecutive white (1,107), black (361), and Hispanic (479) older adults who had their first medical-ICU admission from 2006 through 2009 and survived to hospital discharge. None. We obtained demographic, insurance, and clinical data from electronic health records, determined each patient's neighborhood-level socioeconomic data from 2010 U.S. Census tract data, and determined death dates using the Social Security Death Index. Subjects had a mean (SD) age of 79 years (8.6 yr) and median (interquartile range) follow-up time of 1.6 years (0.4-3.0 yr). Blacks and Hispanics had similar mortality rates compared with whites (adjusted hazard ratio, 0.92; 95% CI, 0.76-1.11 and adjusted hazard ratio, 0.92; 95% CI, 0.76-1.12, respectively). Compared to those with commercial insurance and Medicare, higher mortality rates were observed for those with Medicare only (adjusted hazard ratio, 1.43; 95% CI, 1.03-1.98) and Medicaid (adjusted hazard ratio, 1.30; 95% CI, 1.10-1.52). Medicaid recipients who were the oldest ICU survivors (> 82 yr), survivors of mechanical ventilation, and discharged to skilled-care facilities had the highest mortality rates (p-for-interaction: 0.08, 0.03, and 0.17, respectively). Mortality after critical illness among older adults varies by insurance coverage but not by race or ethnicity. Those with federal or state insurance coverage only had higher mortality rates than those with additional commercial insurance.

Becoming Reconciled to MedRec

Becoming Reconciled to MedRec

Efficacy of nebulized colistin-based therapy without concurrent intravenous colistin for ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter baumannii.

Although there have been studies regarding the role of nebulized colistin as adjunctive therapy of ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii (CRAB), a paucity of information on the efficacy of nebulized colistin as monotherapy is available. We retrospectively reviewed 219 patients with VAP caused by CRAB treated with either intravenous (n=93) or nebulized colistin (n=126), from March 2010 to November 2015. Factors related to clinical failure was assessed using propensity-score-matched analysis. Of 219 patients, 39 patients from each group (n=78) were matched after covariate adjustment using propensity score. There were no significant differences in baseline characteristics as well as the rates of clinical failure between the propensity-score-matched groups [Odds ratio (OR), 0.48; 95% confidence interval (CI), 0.19-1.19; P=0.11], while a significantly lower rate of acute kidney injury (AKI) during colistin therapy (18% vs. 49%, P=0.004) was observed in nebulized colistin group. In addition, multivariable analysis revealed that nebulized colistin did not significantly alter the rate of clinical failure [adjusted odds ratio (aOR), 0.36; 95% CI, 0.12-1.09; P=0.070]. Instead, medical intensive care unit (ICU) admission (aOR, 7.14; 95% CI, 1.60-32.00; P=0.010), and septic shock (aOR, 3.93; 95% CI, 1.27-12.17; P=0.018) were independent risk factors for clinical failure. Our findings suggest that nebulized colistin-based therapy, even without concurrent administration of intravenous colistin, may be an effective and safe treatment option for VAP caused by CRAB.

Outcomes of nighttime refusal of admission to the intensive care unit: The role of the intensivist in triage

PurposeTo compare outcomes of patients refused medical intensive care unit (MICU) admission overnight to those refused during the day and to examine the impact of the intensivist in triage. Materials and methodsRetrospective, observational study of patients refused MICU admission at an urban university hospital. ResultsOf 294 patients, 186 (63.3%) were refused admission overnight compared to 108 (36.7%) refused during the day. Severity-of-illness by the Mortality Probability Model was similar between the two groups (P=.20). Daytime triage refusals were more likely to be staffed by an intensivist (P=.01). After risk-adjustment, daytime refusals had a lower odds of subsequent ICU admission (OR 0.46, 95% CI 0.22–0.95, P=.04) than patients triaged at night. There was no evidence for interaction between time of triage and intensivist staffing of the patient (P=.99). ConclusionsPatients refused MICU admission overnight are more likely to be later admitted to an ICU than patients refused during the day. However, the mechanism for this observation does not appear to depend on the intensivist's direct evaluation of the patient. Further investigation into the clinician-specific effects of ICU triage and identification of potentially modifiable hospital triage practices will help to improve both ICU utilization and patient safety.

Changing Epidemiology of Dengue Fever: Newer Insights and Current Concepts

Background: Dengue fever (DF) is the most common of the arboviral infections in humans and more than two-fifths of the world's population lives in areas potentially at risk for dengue. Effective vector control, prompt case detection and appropriate clinical management can reduce the mortality from severe dengue. The objective of this paper is to present current epidemiology of dengue in this part of the country and, additionally, reflect on some important clinical issues involved in the management of these cases. The global incidence of DF and dengue hemorrhagic fever (DHF) has increased dramatically in recent decades. Endothelium is the target of the immune-pathological mechanism in DF and DHF, its hallmark being vascular permeability and coagulation disorders. Plasma leakage or capillary leak syndrome (CLS) is the most specific and life-threatening feature of DHF and is considered to be the primary lesion that underlies DHF. Materials and Methods: The present study is a four year (January 2013- December 2016), retrospective observational study. The study population consists of 264 male or female indoor patients with confirmed diagnosis of dengue fever. Inclusion criteria were discharge diagnosis with International Classification of Disease (ICD) code A90 - A91 and availability of minimal dataset (name, registration number, age, sex, diagnosis, symptoms, laboratory investigations, transfusions if any, co-infection, other co-morbidities, date of admission, date of discharge, and discharge status). Indoor files of all these 264 cases were collected from medical records department and data tabulated. The study focuses on incidence and outcomes of CLS in dengue infection along with other various issues among these patients. Results: In all 264 patients were included in the study with a male female ratio of 1.6:1. The youngest and the eldest patient were of 13 year and 95 year age respectively. Primary dengue fever (pDF) was seen in 219 (83%) and secondary dengue fever (sDF) in 45 (17%) cases respectively. Besides fever, chills, vomiting, abdominal pain, body-ache, bleeding manifestations, and hepato-splenomegaly, features of CLS were present in 164 (62.1%) cases. None of the cases had only left side pleural or pericardial effusion. In all 258 (97.7%) cases had thrombocytopenia, 39 (14.8%) cases had bleeding manidestations, 11 (4%) cases had severe organ involvement, 19 (7.2%) cases had co-infections, 43 (16.3%) cases required medical intensive care unit (MICU) admissions, and there were only 4 (1.5%) mortalities. The pathophysiology and management challenges of CLS along with other parameters are discussed. Conclusion: Currently, no specific antiviral therapy exists for dengue virus. With prompt case detection and appropriate clinical management, the case fatality rate (CFR) is declining and the overall CFR in the southeast Asia region is now less than 1%. In our case series it was 1.5%. We conclude that patients of DF with thrombocytopenia and transaminitis should be evaluated early by ultrasonography for CLS. Hemoconcentration and hypoproteinemia are not sensitive tools to pick up capillary leakage in clinical practice. Isolated left side pleural effusion and pericardial effusion are not seen in DF and if present one should look for another cause. The case series raises question on the accepted theory of relation between capillary leakage and severe dengue infection. Further, since capillary leakage was seen in 78.8% of primary dengue infection cases, it also questions the validity of the immune enhancement theory of DHF/severe dengue. Viral burden may be a key factor in determination of disease severity rather than sequential infections or secondary infection. Early detection and appropriate case management practices are critical factors for survival.

A Communications Bundle to Improve Satisfaction for Critically Ill Patients and Their Families: A Prospective, Cohort Pilot Study

ContextCommunication skills training with simulated patients is used by many academic centers, but how to translate skills learned in simulated settings to improve communication in real encounters has not been described. ObjectivesWe developed a communications bundle to facilitate skill transfer from simulation to real encounters and improve patient and/or family satisfaction with physician communication. We tested the feasibility of its use in our hospital's medical intensive care unit (MICU). MethodsThis prospective cohort 2-week feasibility study included patients admitted to the MICU with APACHE IV predicted mortality >30% and/or single organ failure. The communications bundle included simulation communication training for MICU physicians, scheduling a family meeting within 72 hours of MICU admission, standardized pre- and post-meeting team huddles with the aid of a mobile app to set an agenda, choose a communication goal, and get feedback, and documentation of meeting in the electronic medical record. The intervention group receiving the communications bundle was located in a geographically separate unit than the control group receiving standard of care from MICU physicians who had not received training in the communications bundle. Patient satisfaction surveys were given within 48 hours of the family meeting and scores compared between the two groups. We also compared trainee self-perceived communication preparation. ResultsThe intervention group (N = 15) scored significantly higher on satisfaction than the control group (N = 16) (P = 0.018). Intervention group trainees reported improvement in self-perceived communication preparation. ConclusionUse of the communications bundle proved feasible in the MICU and suggests association with improved patient satisfaction and trainee self-perception of communication preparedness.

Should Sickle Cell Disease be Among the Risk Factors for Use of Thromboprophylaxis in Adolescents and Young Adults ?

▪Introduction: As published by Naik both in single-institution and multi-institution data, adults with sickle cell disease have a baseline hypercoagulable state in addition to traditional risk factors. In pediatrics, venous thromboembolism (VTE) is often overlooked because of the low incidence in children. In addition, there is no unified consensus that supports the use of prophylaxis or screening of the pediatric population at risk. Although the incidence of VTE in the general pediatric population is low, there may be those children, including those with sickle cell disease (SCD), who would benefit from VTE prophylaxis.Objectives: Estimate the contribution of sickle cell disease to rates of VTE in adolescents and young adults, compare rates of prophylaxis in the pediatric units versus the adult units, and determine risk factors associated with VTE occurrence in a hospital serving a large population with sickle cell disease.Methods: This study was a retrospective chart review of patients aged 14-25 admitted to the Pediatric Intensive Care Unit (PICU), to the Pediatric Sickle Cell Service, and to the Medical Intensive Care Unit (MICU) between the dates of April 1, 2014 and April 30, 2015. Anyone older than age 18 admitted to the PICU or Pediatric Sickle Cell Service was considered part of pediatrics. Charts were searched manually for incidence of VTE during hospitalization, risk factors for developing VTE, history of prior VTE, use of therapeutic anticoagulation, and prophylaxis use and type. Data was analyzed using a multivariate regression analysis.Results: In the 13-month period, 251 AYA admissions (108 to the PICU and 143 to the Sickle cell Unit) and 67 MICU admissions were reviewed. 66/67 (99%) MICU patients received either chemical or mechanical prophylaxis against VTE compared to 9/251 (3.5%) children. Event rates of VTE were 3/67 (4.5%) in MICU and 2/251 (0.8%) in the Pediatric units - 1 in the Sickle Cell unit and 1 in the PICU. In the pediatric units, none of the patients receiving prophylaxis had an acute VTE and both patients with VTE were not on prophylaxis. Both adolescents had central lines in place at the time of VTE occurrence. Of the MICU events, one patient had SCD and was taking systemic anticoagulation for previous VTE but had a central line in place. The other MICU patients both had infections, one with Crohns Disease and the other with a central line placed (table 2). The multivariate regression analysis demonstrated that prior history of a VTE and prolonged LOS were positively correlated with increased risk for VTE, both with a confidence interval of 95% and a corrected critical value of 0.003 using the Bonferroni correction (table 1).Conclusion: Of the 5 VTE events in the 318 AYA hospitalizations reviewed, two (40%) were in patients with SCD (ages 17 and 24). As expected, overall VTE incidence in AYA is low in our institution, and appear to be associated with heightened inflammation and central line placement. VTE events in the pediatric unit were in patients not receiving any prophylaxis, which is not surprising when VTE prophylaxis orders were rare on the pediatric units (3.5%). In both our pediatric unit cases, prophylaxis may have prevented the VTE. A consensus protocol to identify high risk children is being implemented and refined with ongoing data collection. The data from our hospital AYA population enriched in SCD reinforces previous data from adult sickle cell populations that the magnitude of VTE risk attributable to SCD can be high. SCD probably should be among the screening criteria when deciding VTE prophylaxis in hospitalized adolescents. [Display omitted] [Display omitted] DisclosuresHsu:Purdue Pharma: Research Funding; Gerson Lehman Group: Consultancy; Hilton Publishing: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Astra Zeneca: Consultancy, Research Funding; Eli Lilly: Research Funding; Sancilio: Research Funding; Centers for Medicare and Medicaid Innovation: Research Funding; EMMI Solutions: Consultancy; Mast Therapeutics: Research Funding.

Predicting mortality of patients with cirrhosis admitted to medical intensive care unit: An experience of a single tertiary center

Background and study aimsPrognosis for patients with cirrhosis admitted to a medical intensive care unit (MICU) is poor and no previous studies have been published from Qatar or other countries in the region to investigate this issue. The objective of this study was to assess the predictors for in-hospital mortality and admission of cirrhotic patients to MICU in a single tertiary hospital in Qatar. Patients and methodsAll adult cirrhotic MICU patients hospitalized from 2007 through 2012 to Hamad General Hospital-Qatar were included. We compared them to cirrhotic patients admitted to medical wards during same period of time. All data were recorded and analyzed with respect to demographic parameters, clinical features and laboratory as well as radiology characteristics on day one of admission to MICU. Cirrhosis diagnosis was established either with a liver biopsy or the combination of physical, laboratory and radiologic findings. Predictors of mortality were defined by logistic regression analysis. ResultsThe cohort comprised 109 cirrhotic MICU patients (86.2% males), and their mean age±SD was 51.6±11.5. MICU-cirrhotic patients had longer hospital stays than medical wards-cirrhotic patients (p=0.01). Admission with severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA (Sepsis Related Organ Failure Assessment) score were the independent predicting factors for MICU admission. Mortality was higher for the MICU-cirrhotic group than medical wards group (27 (24.8%) deaths vs. 12 (5.3%) deaths, respectively, p=0.001). In multivariate logistic regression analyses, older age>60years (p=0.04), APACH-II score (p=0.001) and MELD score (p=0.02) were independent predicting factors for overall mortality. ConclusionSevere hepatic encephalopathy, upper gastrointestinal bleeding and SOFA score predict MICU admission of cirrhotic patients. Among MICU cirrhotic patients, older age, APACH-II score and MELD score predict mortality.

Predicting mortality of patients with cirrhosis admitted to medical intensive care unit: Experience of a single tertiary center in Qatar

Background/aims: Prognosis for patients with cirrhosis admitted to medical intensive care unit (MICU) is poor. The objective of this study was to assess the predictors for hospital mortality and admission of cirrhotic patients to MICU in Qatar. Materials and methods: We conducted a retrospective cohort study of consecutive adult cirrhotic medical-ICU patients whom hospitalized from 2007 through 2012 to Hamad General Hospital-Qatar. We compared them to cirrhotic patients who admitted to medical wards during same period of time. All data were recorded and analyzed with respect to demographic parameters, clinical features and laboratory as well as radiology characteristics on day one of admission to MICU. Cirrhosis diagnosis was established either with a liver biopsy or the combination of physical, laboratory and radiologic findings. Predictors of mortality were defined by logistic regression analysis. Results: The cohort comprised 109 cirrhotic MICU patients, 86.2% were males and their mean age ± SD = 51.6 ± 11.5. MICU-cirrhotic had longer hospital length of stay (LoS) than medical wards-cirrhotic (both for survivors and non-survivors). Mortality was higher for the MICU-cirrhotic group than medical wards group (27 (24.8%) deaths vs. 12 (5.3%) deaths, respectively, p = 0.001). In multivariate logistic regression analyses, older age >60 years (p = 0.04), APATCH-II score (p = 0.001) and MELD score (p = 0.02) were independent predicting factors for overall mortality. Furthermore, admission with severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA score were independent predicting factors for MICU admission. Conclusion: Severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA score predict MICU admission of cirrhotic patients. Among MICU cirrhotic patients, older age, APATCH-II score and MELD score predict mortality.

Effect of Timing of Do-Not-Resuscitate Orders on the Clinical Outcome of Critically Ill Patients

Background: Many physicians hesitate to discuss do-not-resuscitate (DNR) orders with patients or family members in critical situa-tions. In the intensive care unit (ICU), delayed DNR decisions could cause unintentional cardiopulmonary resuscitation, patient dis-tress, and substantial cost. We investigated whether the timing of DNR designation affects patient outcome in the medical ICU. Methods: We enrolled retrospective patients with written DNR orders in a medical ICU (13 bed) from June 1, 2014 to May 31, 2015. The patients were divided into two groups: early DNR patients for whom DNR orders were implemented within 48 h of ICU admission, and late DNR patients for whom DNR orders were implemented more than 48 h after ICU admission. Results: Herein, 354 patients were admitted to the medical ICU and among them, 80 (22.6%) patients had requested DNR orders. Of these patients, 37 (46.3%) had designated DNR orders within 48 hours of ICU admission and 43 (53.7%) patients had designated DNR orders more than 48 hours after ICU admission. Compared with early DNR patients, late DNR patients tended to withhold or withdraw life-sustaining management (18.9% vs. 37.2%, p = 0.072). DNR consent forms were signed by family members instead of the patients. Septic shock was the most common cause of medical ICU admission in both the early and late DNR patients (54.1% vs. 37.2%, p = 0.131). There was no difference in in-hospital mortality (83.8% vs. 81.4%, p = 0.779). Late DNR patients had longer ICU stays than early DNR patients (7.4 ± 8.1 vs. 19.7 ± 19.2, p < 0.001). Conclusions: Clinical outcomes are not influenced by the time of DNR designation in the medical ICU. The late DNR group is associ-ated with a longer length of ICU stay and a tendency of withholding or withdrawing life-sustaining treatment. However, further stud-ies are needed to clarify the guideline for end-of-life care in critically ill patients.

Invasive Aspergillosis Associated With Severe Influenza Infections.

Background. Invasive aspergillosis may occur in the setting of severe influenza infections due to viral-induced respiratory epithelium disruption and impaired immune effects, but data are limited.Methods. A retrospective study was conducted among severe influenza cases requiring medical intensive care unit (ICU) admission at an academic center during the 2015–2016 season. Data collected included respiratory cultures, medical conditions and immunosuppressants, laboratory and radiographic data, and outcomes. A systematic literature review of published cases in the English language of aspergillosis complicating influenza was conducted.Results. Six (75%) of 8 ICU influenza cases had Aspergillus isolated; 5 were classified as invasive disease. No ICU patient testing negative for influenza infection developed aspergillosis during the study period. Among cases with invasive aspergillosis, influenza infection was type A (H1N1) (n = 2) and influenza B (n = 3). Published and current cases yielded n = 57 (European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group criteria: 37% proven, 25% probable, and 39% possible cases). An increasing number of cases were reported since 2010. Sixty-five percent of cases lacked classic underlying conditions at admission for aspergillosis, 86% had lymphopenia, and 46% died.Conclusions. Aspergillosis may occur in the setting of severe influenza infections even among immunocompetent hosts. Risks may include influenza A (H1N1) or B infections and viral-induced lymphopenia, although further studies are needed. Prompt diagnosis and antifungal therapy are recommended given high mortality rates.

CARDIAC TAMPONADE OR SOMETHING MORE: WHEN HEMODYNAMICS DON’T IMPROVE WITH PERICARDIOCENTESIS

Hemodynamic instability is a common reason for medical ICU admission. Early identification of shock etiology is essential for optimal management. A 20 year-old woman was admitted to our medical ICU with profound hypotension occurring in the midst of a workup for protracted fatigue, dyspnea, and

Bleeding complications in critically ill patients with liver cirrhosis.

Background/Aims:Patients with liver cirrhosis (LC) are at risk for critical events leading to Intensive Care Unit (ICU) admission. Coagulopathy in cirrhotic patients is complex and can lead to bleeding as well as thrombosis. The aim of this study was to investigate bleeding complications in critically ill patients with LC admitted to a medical ICU (MICU).Methods:All adult patients admitted to our MICU with a diagnosis of LC from January 2006 to December 2012 were retrospectively assessed. Patients with major bleeding at the time of MICU admission were excluded from the analysis.Results:A total of 205 patients were included in the analysis. The median patient age was 62 years, and 69.3% of the patients were male. The most common reason for MICU admission was acute respiratory failure (45.4%), followed by sepsis (27.3%). Major bleeding occurred in 25 patients (12.2%). The gastrointestinal tract was the most common site of bleeding (64%), followed by the respiratory tract (20%). In a multivariate analysis, a low platelet count at MICU admission (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and sepsis (OR, 8.35; 95% CI, 1.04 to 67.05) were independent risk factors for major bleeding. The ICU fatality rate was significantly greater among patients with major bleeding (84.0% vs. 58.9%, respectively; p = 0.015).Conclusions:Major bleeding occurred in 12.2% of critically ill cirrhotic patients admitted to the MICU. A low platelet count at MICU admission and sepsis were associated with an increased risk of major bleeding during the MICU stay. Further study is needed to better understand hemostasis in critically ill patients with LC.

The significance of clinical scores and biological markers in disease severity, mortality prediction, and justifying hospital admissions in patients with community-acquired pneumonia

There is a higher prevalence of community-acquired pneumonia (CAP) worldwide. The stratification of the severity and prognosis of CAP is a vital feature as it is one of the most common causes of mortality among other infectious diseases in the developed countries. The mortality rate of patients with CAP depends on the severity of the disease, treatment failure along with the requirement of hospitalization and/or Intensive Care Unit (ICU) management which is quite cost-effective. To improve the outcomes in the management of CAP, there has recently been a significant attention paid to focus on the use and implication of evidence-based scoring systems and biological markers to justify hospital admission in either acute medical settings or ICU, also to classify the disease severity which will help in predicting the mortality rate. We have reviewed the significance of established and newly developed clinical scores, biological markers, and cytokines whether used alone or in conjunction with the clinical severity scores to assess the severity of the disease, prediction of early or late treatment failure, justify the acute in-hospital or ICU admission, and for the identification of short- and long-term mortality. In conclusion, the incorporation of the biological markers in the prognostic scales of the clinical scoring systems may improve the mortality prediction value of patients with CAP requiring acute hospitalization or ICU care and further studies at a larger scale are needed to corroborate the additive value of biological markers.