Admission Sequential Organ Failure Assessment Research Articles

Rapid response system for critically ill patients with haematological malignancies: A pre- and post-intervention study.

This study aimed to determine whether implementing a rapid response system (RRS) is associated with improved short-term outcomes in critically ill patients with haematological malignancies. Our monocentric pre- versus post-intervention study was conducted between January 2012 and April 2020. RRS was activated at early signs of haemodynamic or respiratory failure. The primary outcome was the reduction in Sequential Organ Failure Assessment (SOFA) score on Day 3 after intensive care unit (ICU) admission. Secondary outcomes included time to ICU admission and mortality. A total of 209 patients with a median age of 59 years were enrolled (108 in the pre-intervention period and 101 in the post-intervention period). 22% of them had received an allogeneic transplant. The post-intervention period was associated with a shorter time to ICU admission (195 vs. 390 min, p < .001), a more frequent favourable trend in SOFA score (57% vs. 42%, adjusted odds ratio, 2.02, 95% confidence interval, 1.09 to 3.76), no significant changes in ICU (22% vs. 26%, p = .48) and 1-year (62% vs. 58%, p = .62) mortality rates. Detection of early organ failure and activation of an RRS was associated with faster ICU admission and lower SOFA scores on Day 3 of admission in critically ill patients with haematological malignancies.

QSOFA combined with suPAR for early risk detection and guidance of antibiotic treatment in the emergency department: a randomized controlled trial

BackgroundSepsis guidelines suggest immediate start of resuscitation for patients with quick Sequential Organ Failure Assessment (qSOFA) 2 or 3. However, the interpretation of qSOFA 1 remains controversial. We investigated whether measurements of soluble urokinase plasminogen activator receptor (suPAR) may improve risk detection when qSOFA is 1.MethodsThe study had two parts. At the first part, the combination of suPAR with qSOFA was analyzed in a prospective cohort for early risk detection. At the second part, the double-blind, randomized controlled trial (RCT) SUPERIOR evaluated the efficacy of the suPAR-guided medical intervention. SUPERIOR took place between November 2018 and December 2020. Multivariate stepwise Cox regression was used for the prospective cohort, while univariate and multivariate logistic regression was used for the RCT. Consecutive admissions at the emergency department (ED) with suspected infection, qSOFA 1 and suPAR ≥ 12 ng/mL were allocated to single infusion of placebo or meropenem. The primary endpoint was early deterioration, defined as at least one-point increase of admission Sequential Organ Failure Assessment (SOFA) score the first 24 h.ResultsMost of the mortality risk was for patients with qSOFA 2 and 3. Taking the hazard ratio (HR) for death of patients with qSOFA = 1 and suPAR < 12 ng/mL as reference, the HR of qSOFA = 1 and suPAR ≥ 12 ng/mL for 28-day mortality was 2.98 (95% CI 2.11–3.96). The prospective RCT was prematurely ended due to pandemia-related ED re-allocations, with 91 patients enrolled: 47 in the placebo and 44 in the meropenem arm. The primary endpoint was met in 40.4% (n = 19) and 15.9% (n = 7), respectively (difference 24.5% [5.9–40.8]; odds ratio 0.14 [0.04–0.50]). One post hoc analysis showed significant median changes of SOFA score after 72 and 96 h equal to 0 and − 1, respectively.ConclusionsCombining qSOFA 1 with the biomarker suPAR improves its prognostic performance for unfavorable outcome and can help decision for earlier treatment.Trial registration EU Clinical Trials Register (EudraCT, 2018-001008-13) and Clinical-Trials.gov (NCT03717350). Registered 24 October 2018.

Static Respiratory System Compliance as a Predictor of Extubation Failure in Patients with Acute Respiratory Failure.

Ventilator weaning protocols rely in part on objective indices to best predict extubation failure in the critically ill. We investigated static respiratory system compliance (RC) as a predictor of extubation failure, in comparison to extubation readiness using rapid shallow breathing index (RSBI). This was a cross-sectional, multi-institutional study of mechanically ventilated patients admitted between 12/01/2017 and 12/01/2019. All patients older than 18years with a documented spontaneous breathing trial and extubation trial were included. RC and RSBI were calculated prior to the extubation trial. The primary outcome was extubation failure-defined as need for reintubation within 72h from time of extubation. Of the 2263 patients, 55.8% were males with a mean age of 68 years. The population consisted mostly of Caucasians (73%) and African Americans (20.4%). 274 (12.1%) patients required reintubation within 72h. On multivariate logistic regression after adjusting for age, sex, body mass index (BMI), admission Sequential Organ Failure Assessment (SOFA) score, number of ventilator days, and the P/F ratio on the day of extubation, RC remained the strongest predictor for extubation failure at 24h (aOR 1.45; 95% CI 1.00-2.10) and 72h (aOR 1.58; 95% CI 1.15-2.17). There was no significant association between RSBI and extubation failure at 24 (aOR 1.00; 95% CI 0.99-1.01) or at 72h (aOR 1.00; 95% CI 0.99-1.01). RC measured on the day of extubation is a promising physiological discriminant to potentially risk stratify patients with acute respiratory failure for extubation readiness. We recommend further validation studies in prospective cohorts.

Factors associated with intubation in patients with acute hypoxaemic respiratory failure treated with high-flow nasal cannula oxygen therapy: A prospective, observational study

BackgroundHigh-flow nasal cannula (HFNC) oxygen is an alternative to conventional oxygen in acute hypoxaemic respiratory failure. Some patients require intubation, with a risk of delay; thus, early predictors may identify those requiring earlier intubation. The “ROX” index (ratio of pulse oximetry/fraction of inspired oxygen to respiratory rate) predicts intubation in patients with pneumonia treated with HFNC therapy, but this index has not been validated in non-pneumonia causes of acute hypoxaemic respiratory failure. Aim/ObjectiveThe aim of this study was to identify factors associated with intubation in a heterogeneous group of patients with acute hypoxaemic respiratory failure treated with HFNC oxygen. MethodsThis prospective observational study was undertaken in an Australian tertiary intensive care unit and included patients over 18 y of age with acute hypoxaemic respiratory failure who were treated with oxygen via HFNC. Vital signs and arterial blood gases were recorded prospectively at baseline and regular prespecified intervals for 48 h after HFNC initiation. Multivariate logistic regression was used to identify the factors associated with intubation. ResultsForty-three patients were included (N = 43). The multivariate factors associated with intubation were admission Sequential Organ Failure Assessment score (odds ratio [OR]: 1.94 [95% confidence interval {CI}: 1.06–3.57]; p = 0.032) and Pneumonia Severity Index (OR: 0.95 [95% CI: 0.90–0.99]; p = 0.034). The ROX index was not independently associated with intubation when adjusted for Sequential Organ Failure Assessment score (OR: 0.71 [95% CI: 0.47–1.06]; p = 0.09). There was no difference in mortality between patients intubated early (<24 h) compared to those intubated late. ConclusionsIntubation was associated with admission Sequential Organ Failure Assessment score and Pneumonia Severity Index. The ROX index was not associated with intubation when adjusted for admission Sequential Organ Failure Assessment score. Outcomes were similar irrespective of whether patients were intubated late rather than early.

A study of predictors of outcome in paediatric intensive care unit with special reference to SOFA score

Background: Multi-organ dysfunction syndrome (MODS) is the leading cause of morbidity and mortality for patients admitted in Pediatric Intensive care unit. The Sequential organ failure assessment (SOFA) score is an objective score that allows for calculation of both the number and the severity of organ dysfunction in six organ systems. It is a six-organ dysfunction score measuring multiple organ failure daily. Each organ is graded from 0 (normal) to 4 (the most abnormal). This scoring system guides the efficient utilization of hospital resources, especially in a resource starved setting and useful to evaluate the prognostication, to counsel the guardians and to decide therapeutic interventions. The score can also be a useful in clinical research tool to evaluate various therapeutic interventions in MODS. The aim of the study was to predict outcome in pediatric intensive care unit with special reference to SOFA score in patients admitted to civil hospital, Ahmedabad. Methods: We have randomly selected 120 patients who were admitted in pediatric intensive care unit of tertiary care hospital and full-filing inclusion and exclusion criteria included in our study. Results: There are multiple factors responsible for predicting the outcome in critically ill patients admitted in pediatric intensive care unit. Patients with complete immunization status have better outcome as compared to patients with incomplete immunization and unimmunized status. Patients with higher socioeconomic class have slightly better outcome as compared to patients with lower socioeconomic class. Conclusions: SOFA score is a good objective score as a predictor of mortality in critically ill patients. But, if SOFA is calculated at the time of admission, then it has poor diagnostic accuracy in prediction of outcome. So, SOFA score at 72 hours of admission (T72) and delta SOFA (T72-T0) are better predictors of poor outcome as compared to SOFA score at admission (T0).

Characterization of Mortality by Sepsis Source in Patients Admitted to the Surgical Intensive Care Unit

IntroductionThe impact of infectious source on sepsis outcomes for surgical patients is unclear. The objective of this study was to evaluate the association between sepsis sources and cumulative 90-d mortality in patients admitted to the surgical intensive care unit (SICU) with sepsis. MethodsAll patients admitted to the SICU at an academic institution who met sepsis criteria (2014-2019, n = 1296) were retrospectively reviewed. Classification of source was accomplished through a chart review and included respiratory (RT, n = 144), intra-abdominal (IA, n = 859), skin and soft tissue (SST, n = 215), and urologic (UR, n = 78). Demographics, comorbidities, and clinical presentation were compared. Outcomes included 90-d mortality, respiratory and renal failure, length of stay, and discharge disposition. Cox-proportional regression was used to model predictors of mortality; P < 0.05 was significant. ResultsPatients with SST were younger, more likely to be diabetic and obese, but had the lowest total comorbidities. Median admission sequential organ failure assessment scores were highest for IA and STT and lowest in urologic infections. Cumulative 90-d mortality was highest for IA and RT (35% and 33%, respectively) and lowest for SST (20%) and UR (8%) (P < 0.005). Compared to the other categories, UR infections had the lowest SICU length of stay and the highest discharge-to-home (57%, P < 0.0005). Urologic infections remained an independent negative predictor of 90-d mortality (odds ratio 0.14, 95% confidence interval: 0.1-0.4), after controlling for sequential organ failure assessment. ConclusionsUrologic infections remained an independent negative predictor of 90-d mortality when compared to other sources of sepsis. Characterization of sepsis source revealed distinct populations and clinical courses, highlighting the importance of understanding different sepsis phenotypes.

Scope and mortality of adult medical ICU patients in an Eastern Cape tertiary hospital.

The characteristics and mortality outcomes of patients admitted to South African intensive care units (ICUs) owing to medical conditions are unknown. Available literature is derived from studies based on data from high-income countries. To determine ICU utilisation by medical patients and evaluate the scope of admissions and clinical associations with hospital mortality in ICU patients 12 years and older admitted to an Eastern Cape tertiary ICU, particularly in the subset with HIV disease. A retrospective descriptive one-year cohort study. Data were obtained from the LivAKI study database and demographic data, comorbidities, diagnosis, and mortality outcomes and associations were determined. There were 261 (29.8%) medical ICU admissions. The mean age of the cohort was 40.2 years; 51.7% were female. When compared with the surgical emergencies, the medical subgroup had higher sequential organ failure assessment (SOFA) scores (median score 5 v. 4, respectively) and simplified acute physiology score III (SAPS 3) scores (median 52.7 v. 48.5), a higher incidence of acute respiratory distress syndrome (ARDS) (7.7% v. 2.9%) and required more frequent dialysis (20.3% v. 5.5%). Of the medical admissions, sepsis accounted for 32.4% of admission diagnoses. The HIV seroprevalence rate was 34.0%, of whom 57.4% were on antiretroviral therapy. ICU and hospital mortality rates were 11.1% and 21.5% respectively, while only acute kidney injury (AKI) and sepsis were independently associated with mortality. The HIV-positive subgroup had a higher burden of tuberculosis (TB), higher admission SOFA and SAPS 3 scores and required more organ support. Among medical patients admitted to ICU, there was a high HIV seroprevalence with low uptake of antiretroviral therapy. Sepsis was the most frequently identified ICU admission diagnosis. Sepsis and AKI (not HIV) were independent predictors of mortality. Co-infection with HIV and TB was associated with increased mortality. The epidemiology and outcomes of adults who are critically ill from medical conditions in South African intensive care units was previously unknown but has been described in this study. The association of sepsis, TB, HIV and acute kidney injury with mortality is discussed.

Abstract 14539: Interhospital Differences in the Use of Critical Care Therapies in Coronary Intensive Care Units and Its Association With In-Hospital Mortality: Insights From the Critical Care Cardiology Trials Network

Background: Previous studies have shown wide interhospital variation in cardiovascular intensive care unit (CICU) admission practices and use of critical care restricted therapies and monitoring (CCRx), but little is known about practice differences among tertiary and academic CICUs. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multicenter registry of tertiary and academic CICUs in the USA and Canada that contributed consecutive patient data in annual 2-month periods from 2017 to 2021. The analysis included 13,318 admissions across 28 sites and compared interhospital variability in CCRx and its association with in-hospital survival. Results: CCRx was provided to 61.4% (interhospital range 28.3 - 86.7%) of CICU patients. Admissions to CICUs in the highest tertile of CCRx utilization, compared with the lower tertile, had a greater burden of comorbidities; less frequently admitted patients with ACS (18.7% vs 35.8%); more frequently admitted cardiac arrest (4.9% vs 2.6%) or cardiogenic shock (5.8% vs 1.9%); and had higher median admission Sequential Organ Failure Assessment (SOFA) scores (5.0 vs 2.0), lactate (1.9 vs 1.8 mmol/L), and creatinine (1.3 vs 1.1 mg/dL) levels. Unadjusted in-hospital mortality varied widely between CICUs (median 12.6%; range 4.0-23.5%; p&lt;0.001). After adjustment for patient differences, the correlation between CICU provision of CCRx and in-hospital mortality was weak (r=0.287, p&lt;0.001). Conclusions: In a large registry of tertiary and academic CICUs, there was large interhospital variability in the provision of CCRx. The weak adjusted correlation with in-hospital mortality suggests that standardized CICU admission criteria could reduce disparities in admission practices and improve health-resource allocation. Figure 1: Unadjusted correlation between individual CICU utilization of critical care restricted therapies and in-hospital all-cause mortality

Gastrointestinal dysfunction is associated with mortality in severe burn patients: a 10-year retrospective observational study from South China

BackgroundData on severe and extensive burns in China are limited, as is data on the prevalence of a range of related gastrointestinal (GI) disorders [such as stress ulcers, delayed defecation, opioid-related bowel immotility, and abdominal compartment syndrome (ACS)]. We present a multicentre analysis of coincident GI dysfunction and its effect on burn-related mortality.MethodsThis retrospective analysis was conducted on patients with severe [≥ 20% total burn surface area (TBSA)] and extensive (> 50% TBSA or > 25% full-thickness TBSA) burns admitted to three university teaching institutions in China between January 1, 2011 and December 31, 2020. Both 30- and 90-day mortality were assessed by collating demographic data, burn causes, admission TBSA, % full-thickness TBSA, Baux score, Abbreviated Burn Severity Index (ABSI) score, and Sequential Organ Failure Assessment (SOFA) score, shock at admission and the presence of an inhalation injury. GI dysfunction included abdominal distension, nausea/vomiting, diarrhoea/constipation, GI ulcer/haemorrhage, paralytic ileus, feeding intolerance and ACS. Surgeries, length of intensive care unit (ICU) stay, pain control [in morphine milligram equivalents (MME)] and overall length of hospital stay (LOHS) were recorded.ResultsWe analyzed 328 patients [75.6% male, mean age: (41.6 ± 13.6) years] with a median TBSA of 62.0% (41.0–80.0%); 256 (78.0%) patients presented with extensive burns. The 90-day mortality was 23.2% (76/328), with 64 (84.2%) of these deaths occurring within 30 d and 25 (32.9%) occurring within 7 d. GI dysfunction was experienced by 45.4% of patients and had a significant effect on 90-day mortality [odds ratio (OR) = 14.070, 95% confidence interval (CI) 5.886–38.290, P < 0.001]. Multivariate analysis showed that GI dysfunction was associated with admission SOFA score and % full-thickness TBSA. Overall, 88.2% (67/76) of deceased patients had GI dysfunction [hazard ratio (HR) for death of GI dysfunction = 5.951], with a survival advantage for functional disorders (diarrhoea, constipation, or nausea/vomiting) over GI ulcer/haemorrhage (P < 0.001).ConclusionPatients with severe burns have an unfavourable prognosis, as nearly one-fifth died within 90 d. Half of our patients had comorbidities related to GI dysfunction, among which GI ulcers and haemorrhages were independently correlated with 90-day mortality. More attention should be given to severe burn patients with GI dysfunction.

Discussion Guide for the Brogan Article.

Discussion Guide for the Brogan Article.

Adult Admissions to a Canadian PICU during the COVID-19 Pandemic

AbstractIn response to the burden of coronavirus disease 2019 (COVID-19) and overwhelmed intensive care unit (ICU) resources, some pediatric intensive care units (PICUs) have had to adapt. The purpose of this study was to assess the criticality, scope of diagnosis, and outcomes of an adult cohort admitted to a Canadian PICU. A retrospective chart review was completed on all patients between 17 and 50 years of age admitted to the PICU between June 2020 and December 2021. Admission data included body mass index (BMI), admission sequential organ failure assessment score (SOFA), COVID-19 status, diagnosis, and comorbidities. The duration of ventilatory support, PICU and hospital admission, and mortality and discharge disposition were assessed. Discrete variables were reported as percentages and continuous data as means with standard deviations or medians with interquartile range. Sixty-five adult patients were admitted to the PICU for a total of 437 days, with a mean SOFA score of 6.6 and the overall mortality rate of 4.6%. Six patients were diagnosed with COVID-19 pneumonia, were admitted with a mean SOFA score of 11.8 and a BMI of 38.3 kg/m2, and all were discharged to the ward. During the COVID-19 pandemic, pediatric intensivists in a Canadian PICU managed adult patients up to 50 years of age with high criticality and broad-ranging diagnoses with a low mortality rate. PICUs may be a safe critical care decompression option for adult ICUs during future endemics or pandemics.

Sepsis in a Combined Medical and Surgical High Dependency/Intensive Care Unit in Singapore: A Cohort Study and Survival Analysis.

BackgroundSepsis is a common indication for intensive care unit (ICU) admission and is associated with significant mortality and morbidity. The aim of our study was to first assess the incidence, severity, short-term and long-term mortality of sepsis in a combined medical and surgical high dependency/ ICU in Singapore, and to identify factors associated with increasing short-term and long-term mortality.MethodsAll admissions from July 1 to December 31, 2017 were retrospectively screened and clinical data were collected. Patients were followed up until 3 years post ICU admission.ResultsOf a total 1526 admissions, 281 had infection at ICU admission, and 254 (16.6%) fulfilled sepsis-3 criteria for sepsis. A total of 141 (9.2%) had septic shock. The 30-day, 1-year, 2-year and 3-year mortality of sepsis patients were 19.3%, 25.2%, 30.3% and 32.3%, respectively. Lung was the most common site of infection. Compared with 30-day sepsis survivors, non-survivors were older (median age 70 vs 63, P <0.001), had higher percentage of lung infection (65.3% vs 36.1%, P <0.05), higher admission Sequential Organ Failure Assessment (SOFA) score (median 9 vs 5, P <0.001), and longer ICU stay (median days: 4 vs 3, P = 0.037). In stepwise Cox regression analysis, lung infection was an independent risk factor for both increasing 30-day and 3-year mortality. Immunocompromised host, increasing age and SOFA score were associated with higher 30-day mortality. Diabetes, admission quick Sequential Organ Failure Assessment (qSOFA) score >1 and unplanned ICU re-admission were associated with increasing 3-year mortality in 30-day survivors.ConclusionOur retrospective cohort single center study first reported sepsis admission incidence of 16.6% in a combined medical and surgical high dependency/ICU in Singapore, with significant short-term and long-term mortality. Lung infection was an independent risk factor for both 30-day and 3-year mortality.

Comparison of critically ill COVID-19 and influenza patients with acute respiratory failure.

BackgroundCoronavirus disease 2019 (COVID-19) is one of the biggest pandemic causing acute respiratory failure (ARF) in the last century. Seasonal influenza carries high mortality, as well. The aim of this study was to compare features and outcomes of critically-ill COVID-19 and influenza patients with ARF.MethodsPatients with COVID-19 and influenza admitted to intensive care unit with ARF were retrospectively analyzed.ResultsFifty-four COVID-19 and 55 influenza patients with ARF were studied. Patients with COVID-19 had 32% of hospital mortality, while those with influenza had 47% (P=0.09). Patients with influenza had higher Eastern Cooperative Oncology Group, Clinical Frailty Scale, Acute Physiology and Chronic Health Evaluation II and admission Sequential Organ Failure Assessment (SOFA) scores than COVID-19 patients (P<0.01). Secondary bacterial infection, admission acute kidney injury, procalcitonin level above 0.2 ng/ml were the independent factors distinguishing influenza from COVID-19 while prone positioning differentiated COVID-19 from influenza. Invasive mechanical ventilation (odds ratio [OR], 42.16; 95% confidence interval [CI], 9.45–187.97), admission SOFA score more than 4 (OR, 5.92; 95% CI, 1.85–18.92), malignancy (OR, 4.95; 95% CI, 1.13–21.60), and age more than 65 years (OR, 3.31; 95% CI, 0.99–11.03) were found to be independent risk factors for hospital mortality.ConclusionsThere were few differences in clinical features of critically-ill COVID-19 and influenza patients. Influenza cases had worse performance status and disease severity. There was no significant difference in hospital mortality rates between COVID-19 and influenza patients.

Prognostic Value of Sequential Organ Failure Assessment (SOFA) Score in Critically-Ill Combat-Injured Patients.

Background: Infection is a frequent and serious complication after combat-related trauma. The Sequential Organ Failure Assessment (SOFA) score has been shown to have predictive value for outcomes, including sepsis and mortality, among various populations. We evaluated the prognostic ability of SOFA score in a combat-related trauma population. Methods: Combat casualties (2009-2014) admitted to Landstuhl Regional Medical Center (LRMC; Germany) intensive care unit (ICU) within 4 days post-injury followed by transition to ICUs in military hospitals in the United States were included. Multivariate logistic regression was used to determine predictive effect of selected variables and receiver operating characteristic (ROC) curve analysis was used to evaluate overall accuracy of SOFA score for infection prediction. Results: Of the 748 patients who met inclusion criteria, 436 (58%) were diagnosed with an infection (32% bloodstream, 63% skin and soft tissue, and 40% pulmonary) and were predominantly young (median 24 years) males. Penetrating trauma accounted for 95% and 86% of injuries among those with and without infections, respectively (p < 0.001). Median LRMC admission SOFA score was 7 (interquartile range [IQR]: 4-9) in patients with infections versus 4 (IQR: 2-6) in patients without infections (p < 0.001). Thirty-day mortality was 2% in both groups. On multivariate regression, LRMC SOFA score was independently associated with infection development (odds ratio: 1.2; 95% confidence interval: 1.1-1.3). The ROC curve analysis revealed an area under the curve of 0.69 for infection prediction, and 0.80 for mortality prediction. Conclusions: The SOFA scores obtained up to 4 days post-injury predict late onset infection occurrence. This study revealed that for every 1 point increase in LRMC SOFA score, the odds of having an infection increases by a factor of 1.2, controlling for other predictors. The use of SOFA score in admission assessments may assist clinicians with identifying those at higher risk of infection following combat-related trauma.

Risk Factors for Delirium and Association of Antipsychotic Use with Delirium Progression in Critically Ill Trauma Patients.

Delirium occurs frequently in critically ill and injured patients and is associated with significant morbidity and mortality. Limited data exists on the risk factors for developing delirium in critically ill trauma patients and the effect of antipsychotic (AP) medications on delirium progression. The objective of this study is to determine the incidence of delirium in critically ill trauma versus non-trauma surgical patients and determine if the presence of trauma was associated with intensive care unit (ICU) delirium. Secondary outcomes included identifying risk factors for delirium and determining the impact of AP medication use on delirium progression in critically ill trauma patients. This retrospective review studies adult trauma/surgical ICU patients admitted between May 2017-July 2018 to a level I trauma and tertiary referral center. Regression modeling was used to determine the impact of AP use on delirium-free days. Delirium was more common in critically ill trauma patients versus non-trauma surgical ICU patients [54/157 (34.4%) vs 42/270 (15.6%), P < .001]. Of the 54 trauma patients with delirium, 28 (52%) received an AP medication for delirium treatment and in the multiple linear regression analysis, AP use was significantly associated with fewer delirium-free days (P = .02). Higher admission sequential organ failure assessment scores and increased length of stay were significantly associated with delirium onset in critically ill trauma patients. Use of AP medications for delirium treatment in this population had a negative impact on delirium-free days.

Predictive value of serial evaluation of the Sequential Organ Failure Assessment (SOFA) score for intensive care unit mortality in critically ill patients with COVID-19: a retrospective cohort study.

The Sequential Organ Failure Assessment (SOFA) score has been developed to score the severity of organ dysfunction in critically ill sepsis patients and has been proven to have a high predictive value for intensive care unit (ICU) mortality in severely ill patients. Our goal was to evaluate the prognostic value of the SOFA score as well as trends in SOFA score for ICU mortality in COVID-19 patients. All consecutive patients with confirmed COVID-19 pneumonia admitted to the ICU between March 13th, 2020, and October 17th, 2020 were included in this retrospective cohort study. The worst SOFA score was evaluated daily. Multiple logistic regression models were used to evaluate the predictive value of SOFA in ICU mortality. 103 patients were included in this study. 30 patients (29%) died during their ICU stay and 73 (71%) patients were discharged alive. The ICU admission SOFA score was 5.2 ± 3.3 in ICU non-survivors vs. 4.3 ± 2.9 in ICU survivors (P = 0.15). The maximum SOFA score in ICU non-survivors was 11.7 ± 4.7 vs. 7.4 ± 4.3 in ICU survivors. SOFA scores increased the first week in both survivors and non-survivors, but the increase was less pronounced in survivors. In the multiple logistic regression models, neither admission SOFA score nor combination with delta SOFA in the first 48 hours was statistically significantly related to ICU mortality. Only the maximum SOFA score remained significant (OR = 1.23, 95% CI: 1.11-1.37, P < 0.001) in the multiple logistic models with an AUC of 0.91. Evaluation of SOFA scores in the first 48 hours after ICU admission is not a good prognostic indicator in COVID-19 patients. Only the maximum SOFA score was predictive for ICU mortality.

Kinetics of antibody response in critically ill patients with Middle East respiratory syndrome and association with mortality and viral clearance

The objective of this study is to examine the IgG antibody response in critically ill patients with the Middle East respiratory syndrome (MERS) and to examine the association of early antibody response with mortality and viral clearance. We collected blood samples from 40 consecutive real-time reverse transcription-polymerase chain reaction (rRT-PCR) confirmed critically ill MERS patients on ICU days 1, 3, 7, 14 and 28. MERS-CoV antibodies were detected by enzyme-linked immunosorbent assay (ELISA), using wells coated with MERS-CoV S1 antigen. Patients were admitted to ICU after a median (Q1, Q3) of 9 (4, 13) days from onset of symptoms with an admission Sequential Organ Failure Assessment (SOFA) score of 11 (6.5, 12). Among the study cohort, 38 patients (95%) received invasive ventilation, 35 (88%) vasopressors, 21 (53%) renal replacement therapy and 17 (43%) corticosteroids. Median (Q1,Q3) ELISA optical density (OD) ratio significantly increased with time (p < 0.001) from 0.11 (0.07, 1.43) on day 1; to 0.69 (0.11, 2.08) on day 3, 2.72 (1.84, 3.54) on day 7, 2.51 (0.35, 3.35) on day 14 and 3.77 (3.70, 3.84) on day 28. Early antibody response (day 1–3) was observed in 13/39 patients (33%) and was associated with lower mortality (hazard ratio: 0.31, 95% CI 0.10, 0.96, p = 0.04) but was not associated with faster clearance of MERS-CoV RNA. In conclusion, among critically ill patients with MERS, early antibody response was associated with lower mortality but not with faster clearance of MERS-CoV RNA. These findings have important implications for understanding pathogenesis and potential immunotherapy.

Mortality Prediction of COVID-19 Patients at Intensive Care Unit Admission.

BackgroundCoronavirus-2019 (COVID-19) patients admitted to the intensive care unit (ICU) have mortality rates between 30%-50%. Identifying patient factors associated with mortality can help identify critical patients early and treat them accordingly.Patients and methodsIn this retrospective study, the records of patients admitted to the COVID-19 ICU in a single tertiary care hospital from April 2020 to September 2020 were analysed. The clinical and laboratory parameters between patients who were discharged from the hospital (survival cohort) and those who died in the hospital (mortality cohort) were compared. A multivariate logistic regression model was constructed to identify parameters associated with mortality. ResultsA total of 147 patients were included in the study. The age of the patients was 55 (45, 64), median (IQR), years. At admission, 23 (16%) patients were on mechanical ventilation and 73 (50%) were on non-invasive ventilation. Sixty patients (40%, 95% CI: 32.8 to 49.2%) had died. Patients who died had a higher Charlson comorbidity index (CCI): 3 (2, 4) vs. 2 (1, 3), p = 0.0019, and a higher admission sequential organ failure assessment (SOFA) score: 5 (4, 7) vs. 4 (3, 4), p < 0.001. Serum urea, serum creatinine, neutrophils on differential leukocyte count, neutrophil to lymphocyte ratio (N/L ratio), D-dimer, serum lactate dehydrogenase (LDH), and C-reactive protein were higher in the mortality cohort. The ratio of partial pressure of arterial oxygen to fraction of inspired oxygen, platelet count, lymphocytes on differential leukocyte count, and absolute lymphocyte count was lower in the mortality cohort. The parameters and cut-off values used for the multivariate logistic regression model included CCI > 2, SOFA score > 4, D-dimer > 1346 ng/mL, LDH > 514 U/L and N/L ratio > 27. The final model had an area under the curve of 0.876 (95% CI: 0.812 to 0.925), p < 0.001 with an accuracy of 78%. All five parameters were found to be independently associated with mortality. ConclusionsCCI, SOFA score, D-dimer, LDH, and N/L ratio are independently associated with mortality. A model incorporating the combination of these clinical and laboratory parameters at admission can predict COVID-19 ICU mortality with good accuracy.

Outcomes of Critically Ill Lung Cancer Patients Initiating Targeted Therapy or Immunotherapy in the Intensive Care Unit: A Single-Center Report.

Introduction: Targeted therapy and immune checkpoint inhibitors (ICI) have drastically improved outcomes of metastatic non-small cell lung cancer (NSCLC) patients in outpatient settings. Because trials on critically ill patients are improbable, little is known about their efficacy among patients admitted to intensive care units (ICU). Methods: We retrospectively analyzed the clinical outcomes of critically-ill NSCLC patients receiving either ICI or targeted therapy during ICU admission at the MD Anderson Cancer Center from April 2016 to August 2020. We collected data on ICU admission diagnoses, sequential organ failure assessment (SOFA), previous cancer therapies, tumor gene mutations or translocations, and PD-L1 expression. Overall survival (OS) was calculated from the date of drug initiation using the Kaplan-Meier method. Results: Of 9898 ICU admissions, 9 patients with metastatic NSCLC who received either targeted therapy (5) or PD-1 ICI (4) during ICU admission were included. The most common reasons for ICU admissions were tumor visceral crisis (3/9) and sepsis (3/9). The median (range) admission SOFA was 4 (2-11). Six patients were naïve to systemic therapy. Five patients required mechanical ventilation. The median OS was 77 days (95%CI, 36-NA), and 5 patients were discharged alive (all received targeted therapy). The median OS of patients who received ICI was 25.5 days (95%CI, 8-NA) and for those who received targeted therapy was 218 days (95%CI, 77-NA). At 6 and 12 months follow-up, 3 and 2 patients who received targeted therapy were still alive, respectively. Conclusions: Our exploratory findings indicate a possible benefit of targeted therapy but suggest a lack of clinical utility of PD-1 ICI for critically ill metastatic NSCLC patients. Because of the small sample size, further studies are needed to expand on this topic.

Brescia-COVID Respiratory Severity Scale (BRCSS) and Quick SOFA (qSOFA) score are most useful in showing severity in COVID-19 patients

In this study, we compare the predictive value of clinical scoring systems that are already in use in patients with Coronavirus disease 2019 (COVID-19), including the Brescia-COVID Respiratory Severity Scale (BCRSS), Quick SOFA (qSOFA), Sequential Organ Failure Assessment (SOFA), Multilobular infiltration, hypo-Lymphocytosis, Bacterial coinfection, Smoking history, hyper-Tension, and Age (MuLBSTA) and scoring system for reactive hemophagocytic syndrome (HScore), for determining the severity of the disease. Our aim in this study is to determine which scoring system is most useful in determining disease severity and to guide clinicians. We classified the patients into two groups according to the stage of the disease (severe and non-severe) and adopted interim guidance of the World Health Organization. Severe cases were divided into a group of surviving patients and a deceased group according to the prognosis. According to admission values, the BCRSS, qSOFA, SOFA, MuLBSTA, and HScore were evaluated at admission using the worst parameters available in the first 24 h. Of the 417 patients included in our study, 46 (11%) were in the severe group, while 371 (89%) were in the non-severe group. Of these 417 patients, 230 (55.2%) were men. The median (IQR) age of all patients was 44 (25) years. In multivariate logistic regression analyses, BRCSS in the highest tertile (HR 6.1, 95% CI 2.105–17.674, p = 0.001) was determined as an independent predictor of severe disease in cases of COVID-19. In multivariate analyses, qSOFA was also found to be an independent predictor of severe COVID-19 (HR 4.757, 95% CI 1.438–15.730, p = 0.011). The area under the curve (AUC) of the BRCSS, qSOFA, SOFA, MuLBSTA, and HScore was 0.977, 0.961, 0.958, 0.860, and 0.698, respectively. Calculation of the BRCSS and qSOFA at the time of hospital admission can predict critical clinical outcomes in patients with COVID-19, and their predictive value is superior to that of HScore, MuLBSTA, and SOFA. Our prediction is that early interventions for high-risk patients, with early identification of high-risk group using BRCSS and qSOFA, may improve clinical outcomes in COVID-19.