All-cause Intensive Care Unit Mortality Research Articles

Challenges Facing Two Outbreaks of Carbapenem-Resistant Acinetobacter baumannii: From Cefiderocol Susceptibility Testing to the Emergence of Cefiderocol-Resistant Mutants.

Carbapenem-resistant Acinetobacter baumannii (CRAB) infections are associated with poor outcomes depending on patient's conditions, clinical severity and type of infection, and treatment is challenging given the limited therapeutic options available. The aim of this study was to describe the clinical and microbiological characteristics of two outbreaks caused by CRAB in an intensive care unit (ICU). In addition, the mechanisms of resistance detected in these strains and the treatment chosen according to the available therapeutic options were analyzed. Overall, 28 patients were included. Ten patients (35.71%) had ventilator-associated pneumonia (VAP), ten (35.71%) had a bloodstream infection (BSI), and eight (28.57%) were only colonized. Recurrent infection occurred in 25% (5/20) of infected patients. Two different strains of A. baumannii were isolated from the index patient of the first outbreak. The first strain belonged to the ST85 and carried the blaNDM-1 carbapenemase gene, while the second belonged to the ST2 and carried blaOXA-23, and blaOXA-66 carbapenemase genes. The phylogenetic analysis revealed that the ST2 strain was the cause of the major outbreak, and mutations in the AmpC gene were related to progressive increasing minimum inhibitory concentration (MIC) and finally, cefiderocol-resistance in one strain. The CRAB isolates from the second outbreak were also identified as ST2. Cefiderocol-resistant strains tests identified by the disc diffusion method were involved in 24% (6/25) of nosocomial infections. Using broth microdilution (BMD) ComASP® only, 33.3% (2/6) of these strains were cefiderocol-resistant. All-cause ICU mortality was 21.4%. Conclusions: Cefiderocol is the first approved siderophore cephalosporin for the treatment of CRAB infections. Cefiderocol-resistant strains were related with blaNDM-1 carbapenemase and mutations in the AmpC gene. Cefiderocol-resistant strains or that cannot be properly interpreted by disk diffusion, should be retested using BMD for definitive categorization.

Association Between Vaccination Status and Mortality Among Intubated Patients With COVID-19–Related Acute Respiratory Distress Syndrome

Although vaccination substantially reduces the risk of severe COVID-19, it is yet unknown whether vaccinated patients who develop COVID-19 and require invasive mechanical ventilation have lower mortality than controls. To examine the association between COVID-19 vaccination status and mortality among critically ill patients who require invasive mechanical ventilation owing to acute respiratory distress syndrome (ARDS) related to COVID-19. This multicenter cohort study was performed between June 7, 2021, and February 1, 2022, among 265 consecutive adult patients with COVID-19 in academic intensive care units who underwent invasive mechanical ventilation owing to ARDS. Patients in the full vaccination group had completed the primary COVID-19 vaccination series more than 14 days but less than 5 months prior to intubation. This time threshold was chosen because guidelines from the US Centers for Disease Control and Prevention recommend a booster dose beyond that time. The remaining patients (ie, those who were unvaccinated, partially vaccinated, or fully vaccinated <14 days or >5 months before intubation) comprised the control group. The primary outcome was time from intubation to all-cause intensive care unit mortality. A Cox proportional hazards regression model including vaccination status, age, comorbid conditions, and baseline Sequential Organ Failure Assessment score on the day of intubation was used. A total of 265 intubated patients (170 men [64.2%]; median age, 66.0 years [IQR, 58.0-76.0 years]; 26 [9.8%] in the full vaccination group) were included in the study. A total of 20 patients (76.9%) in the full vaccination group received the BNT162b2 vaccine, and the remaining 6 (23.1%) received the ChAdOx1 nCoV-19 vaccine. Patients in the full vaccination group were older (median age, 72.5 years [IQR, 62.8-80.0 years] vs 66.0 years [IQR, 57.0-75.0 years]) and more likely to have comorbid conditions (24 of 26 [92.3%] vs 160 of 239 [66.9%]), including malignant neoplasm (6 of 26 [23.1%] vs 18 of 239 [7.5%]), than those in the control group. Full vaccination status was significantly associated with lower mortality compared with controls (16 of 26 patients [61.5%] died in the full vaccination group vs 163 of 239 [68.2%] in the control group; hazard ratio, 0.55 [95% CI, 0.32-0.94]; P = .03). In this cohort study, full vaccination status was associated with lower mortality compared with controls, which suggests that vaccination might be beneficial even among patients who were intubated owing to COVID-19-related ARDS. These results may inform discussions with families about prognosis.

Major adverse cardiac events in critically ill COVID-19 patients

Abstract Background Critically ill patients hospitalized with COVID-19 are at high risk of developing major adverse cardiac events (MACE). Purpose This study aimed to identify independent predictors of MACE after intensive care unit (ICU) admission which could be used to identify high-risk patients who may benefit from preventive strategies. Methods We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19 and followed them for a median period of 7 months. Patients admitted due to trauma or emergent surgery were excluded. Logistic regression analysis was performed to evaluate which clinical characteristics predicted MACE. MACE was defined as all-cause ICU mortality, new-onset heart failure, acute coronary syndrome, ventricular arrythmias, pulmonary embolism, myocarditis, and stroke (ischemic or hemorrhagic). Results A total of 297 patients was included in the analysis. Median age was 62 (IQR 17) years, and most patients were male (198 patients, 66.7%). From a total of 297 patients, 108 (36.4%) developed at least one MACE: ICU all-cause mortality (92 patients, 31.0%), new-onset heart failure (27 patients, 9.1%), acute coronary syndrome (7 patients, 2.4%), ventricular arrythmias (7 patients, 2.4%), pulmonary embolism (13 patients, 4.4%), myocarditis (4 patients, 1.3%), and stroke (5 patients, 1.7%). Univariate logistic regression analysis showed that the clinical variables associated with MACE were male sex, older age, APACHE II score, SAPS II score, hypertension, hyperlipidemia, known coronary artery disease, heart failure, new-onset atrial fibrillation, need for invasive mechanical ventilation, duration of mechanical ventilation, and vasopressor use. In multivariate logistic regression analysis, we found that the MACE's independent predictors were older age, higher APACHE II score, and new-onset atrial fibrillation. Main results are presented in Table 1. Conclusion(s) Among critically ill COVID-19 patients, older age, higher APACHE II score, and new-onset atrial fibrillation independently predicted MACE. Funding Acknowledgement Type of funding sources: None.

Atrial fibrillation in COVID-19 patients admitted to an intensive care unit: prevalence and prognosis

Abstract Background The association between atrial fibrillation (AF) and prognosis has been studied in non-COVID-19 patients, but few studies reflect the reality of critically ill COVID-19 patients admitted to a general intensive care unit (ICU). Purpose This study sought to investigate the relationship between previous and new-onset AF in COVID-19 patients admitted to an ICU and prognosis. Methods We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19 and followed them for a median period of 7 months. Patients admitted due to trauma or emergent surgery were excluded from the analysis. Three groups were identified: without AF (G1), with prior history of AF (G2), and with new-onset AF (G3). Groups were compared, with special interest regarding ICU mortality, duration of mechanical ventilation, length of hospitalization, major adverse cardiac events (MACE), and re-hospitalization. MACE was defined as all-cause ICU mortality, new-onset heart failure, acute coronary syndrome, ventricular arrhythmias, pulmonary embolism, myocarditis, and stroke (ischemic or hemorrhagic). Results A total of 297 patients was included in the analysis: without AF (248 patients, 83.5%), with prior history of AF (15 patients, 5.1%), and with new-onset AF (34 patients, 11.4%). Median age was 62 (IQR 17) years, and most patients were male (198 patients, 66.7%). Patients with a prior history of AF were older [median (IQR), G1 60 (16), G2 71 (12), G3 67 (15) years, p=0.001], were more likely to have a history of coronary artery disease (G1 4.9%, G2 26.7%, G3 11.8%, p=0.002), and history of heart failure (G1 6.5%, G2 33.3%, G3 17.6%, p&amp;lt;0.001). Patients with new-onset AF had a longer duration of mechanical ventilation [median (IQR), G1 9 (13), G2 11 (16), G3 18 (12) days, p&amp;lt;0.001), longer ICU length of stay [median (IQR), G1 12 (10), G2 13 (12), G3 19 (15), p=0.001], higher ICU mortality rate (G1 27.0%, G2 33.3%, G3 58.8%, p=0.001), and higher rate of MACE (G1 31.9%, G2 33.3%, G3 70.6%, p&amp;lt;0.001), compared to the other groups. There were no differences regarding sex distribution, other baseline comorbidities, need for invasive mechanical ventilation, vasopressor use, and re-hospitalization rates among groups. Most AF patients were treated with beta-blockers (39.6%) and amiodarone (77.1%), but only 68.8% of patients received anticoagulation (G2 92.9%, G3 58.8%), which may reflect that physicians underestimate the prognosis of new-onset AF. In multivariate analysis, new-onset AF (OR 3.07, 95% CI 1.42–6.67, p=0.005) and older age (OR 1.07, 95% CI 1.04–1.09, p&amp;lt;0.001) remained independent predictors of ICU mortality. Main results are presented in Table 1. Kaplan-Meier survival curves are presented in Figure 1. Conclusion(s) This study shows that critically ill COVID-19 patients with AF present a worse prognosis compared to patients without AF, and new-onset AF is an independent predictor of ICU mortality and MACE. Funding Acknowledgement Type of funding sources: None.

The Combined Use of Interleukin-6 with Serum Albumin for Mortality Prediction in Critically Ill Elderly Patients: The Interleukin-6-to-albumin Ratio.

The association between interleukin-6 (IL-6) and serum albumin (ALB) with mortality in critically ill elderly patients, either as stand-alone biomarkers or in combination, has been scarcely reported. We, therefore, aimed to investigate the prognostic value of the IL-6-to-albumin ratio in this special population. This was a cross-sectional study conducted in the mixed intensive care unit (ICU) of two university-affiliated hospitals in Malaysia. Consecutive elderly patients (aged above or equal to 60 years) admitted to the ICU, who underwent simultaneous measurement of plasma IL-6 and serum ALB, were recruited. The prognostic value of the IL-6-to-albumin ratio was assessed by analysis of the receiver-operating characteristic (ROC) curve. A total of 112 critically ill elderly patients were recruited. The outcome of all-cause ICU mortality was 22.3%. The calculated IL-6-to-albumin ratio was significantly higher in the non-survivors compared to the survivors {14.1 [interquartile range (IQR), 6.5-26.7] vs 2.5 [(IQR, 0.6-9.2) pg/mL, p <0.001]}. The area under the curve (AUC) of IL-6-to-albumin ratio for discrimination of ICU mortality was 0.766 [95% confidence interval (CI), 0.667-0.865, p <0.001] which was slightly higher than that of IL-6 and albumin alone. The ideal cut-off value of the IL-6-to-albumin ratio was above 5.7 with a sensitivity of 80.0% and specificity of 64.4%. After adjusting for severity of illness, the IL-6-to-albumin ratio remained as an independent predictor of ICU mortality with an adjusted odd ratio of 0.975 (95% CI, 0.952-0.999, p = 0.039). The IL-6-to-albumin ratio offers a slight improvement in mortality prediction than either of its constituent individual biomarkers and as such, it may be a potential tool to aid in the prognostication of critically ill elderly patients although this requires further validation in a larger prospective study. Lim KY, Shukeri WFWM, Hassan WMNW, Mat-Nor MB, Hanafi MH. The Combined Use of Interleukin-6 with Serum Albumin for Mortality Prediction in Critically Ill Elderly Patients: The Interleukin-6-to-albumin Ratio. Indian J Crit Care Med 2022;26(10):1126-1130.

Neutrophil-to-lymphocyte ratio as a predictor of clinical outcomes in critically ill COVID-19 patients: A retrospective observational study.

BackgroundTimely identification of patients at risk of worse clinical outcomes is vital in managing coronavirus disease 2019 (COVID‐19). The neutrophil‐to‐lymphocyte ratio (NLR) calculated from complete blood count can predict the degree of systemic inflammation and guide therapy accordingly. Hence, we did a study to investigate the role of NLR value on intensive care unit (ICU) admission in predicting clinical outcomes of critically ill COVID‐19 patients.MethodsWe conducted a retrospective analysis of electronic health records of COVID‐19 patients admitted to ICUs at Hazm Mebaireek General Hospital, Qatar, from March 7, 2020 to July 18, 2020. Patients with an NLR equal to or higher than the cut‐off value derived from the receiver operating characteristic curve were compared to those with an NLR value below the cut‐off. The primary outcome studied was all‐cause ICU mortality. The secondary outcomes evaluated were the requirement of mechanical ventilation and ICU length of stay (LOS).ResultsFive hundred and nineteen patients were admitted to ICUs with severe COVID‐19 infection during the study period. Overall, ICU mortality in the study population was 14.6% (76/519). NLR on ICU admission of ≥6.55 was obtained using Youden's index to predict ICU mortality, with a sensitivity of 81% and specificity of 41%. Mortality was significantly higher in patients with age ≥60 years (p < 0.001), chronic kidney disease (p = 0.03), malignancy (p < 0.002), and NLR ≥ 6.55 (p < 0.003). There was also a significant association between the requirement of mechanical ventilation (34.7% vs. 51.8%, p < 0.001) and increased ICU LOS (8 vs. 10 days, p < 0.01) in patients with ICU admission NLR ≥ 6.55.ConclusionHigher NLR values on ICU admission are associated with worse clinical outcomes in critically ill COVID‐19 patients.

A Prospective Observational Study to Determine Incidence and Outcome of Sepsis-induced Cardiomyopathy in an Intensive Care Unit.

Sepsis leads to left and/or right ventricular systolic and/or diastolic dysfunction resulting in adverse outcomes. Myocardial dysfunction can be diagnosed by echocardiography (ECHO) and early intervention can be planned. There are lacunae in Indian literature regarding the true incidence of septic cardiomyopathy and its influence on the outcome of patients admitted to intensive care unit (ICU). This prospective observational study was conducted on patients consecutively admitted with sepsis to the ICU of a tertiary care hospital in North India. In these patients, ECHO was performed after 48-72 hours to establish left ventricular (LV) dysfunction, in whom the ICU outcome was analyzed. The incidence of LV dysfunction was 14%. About 42.86% of patients had isolated systolic dysfunction, 7.14% of patients had isolated diastolic dysfunction, and 50.00% of patients had combined LV systolic and diastolic dysfunctions. The average days of mechanical ventilation in patients without LV dysfunction group (group I) was 2.41 ± 3.82 days as compared to 4.43 ± 4.27 days in patients with LV dysfunction (group II) (p = 0.034). Incidence of all-cause ICU mortality was 11 (12.79%) in group I and 3 (21.43%) in group II (p = 0.409). The mean duration of stay in ICU was 8.26 ± 4.41 days in group I as compared to 13.21 ± 6.83 days in group II. We concluded that sepsis-induced cardiomyopathy (SICM) in ICU is quite prevalent and clinically significant. All-cause ICU mortality and length of ICU stay are prolonged in patients with SICM. Bansal S, Varshney S, Shrivastava A. A Prospective Observational Study to Determine Incidence and Outcome of Sepsis-induced Cardiomyopathy in an Intensive Care Unit. Indian J Crit Care Med 2022;26(7):798-803.

Association Between High Serum Anion Gap and All-Cause Mortality in Non-Traumatic Subarachnoid Hemorrhage: A Retrospective Analysis of the MIMIC-IV Database.

Background:High serum anion gap (AG) on admission is often correlated with poor outcomes in critically ill patients; however, data in patients with non-traumatic subarachnoid hemorrhage (SAH) are lacking. Herein, we aimed to identify the association between serum AG and all-cause mortality in patients with non-traumatic SAH.MethodsA retrospective analysis of data from the Medical Information Mart for Intensive Care (MIMIC-IV) database was performed on critically ill patients with non-traumatic SAH. Serum AG was collected on Intensive Care Unit (ICU) admission, and ICU and hospital all-cause mortality were analyzed. The multivariate Cox proportional hazard regression model and Kaplan-Meier survival curve analysis were used to analyze the correlation of serum AG with ICU and hospital all-cause mortality. Furthermore, interaction and subgroup analyses were evaluated for the consistency of these correlations.ResultsA total of 893 patients with non-traumatic SAH were included in this study. The all-cause mortality in ICU and hospital were 14.8% (132/893), and 18.9% (169/893), respectively. Multivariate analysis after adjusting for potential confounders indicated that high serum AG levels (≥16 mmol/L) were associated with increased risk of ICU and hospital all-cause mortality as compared to that with low serum AG levels (<16mmol/L), (hazards ratio (HR): 2.31 [95% CI: 1.58–3.38]) and HR: 1.91 [95% CI: 1.36–2.67)], respectively). Similarly, the Kaplan–Meier (K–M) survival curve also showed that patients with high serum AG levels presented with a lower survival rate. Stratified analyses further showed that depending on the variable testes, an association between higher serum AG levels and hospital all-cause mortality in different subgroups was observed.ConclusionAmong patients with non-traumatic SAH, high serum AG level at ICU admission was associated with increased ICU and hospital all-cause mortality.

Early Renal-Replacement Therapy May Reduce the All-Cause Mortality of Severe COVID-19: An Observational Cohort Study

Introduction: The efficacy of renal-replacement treatment (RRT) remains to be validated in COVID-19. In this retrospective cohort study, we aimed to assess the efficacy of early initiation of RRT in intensive care unit (ICU) adults with severe COVID-19. Methods: Fifty-eight adult patients in ICU with critically ill or severe COVID-19 with a tendency of critical illness were recruited from February 9, 2020, to March 30, 2020. Early RRT were determined by the ICU medical team based on boom in cytokines levels, increased organs injury/failure, and rapid aggravation of condition. All participants were followed up from the first day of ICU admission to March 30, 2020. The primary outcome was all-cause mortality in ICU. Results: The mean age of the cohort was 68.4 ± 14.6 years, with 81.0% having at least one comorbidity before hospitalization. Twenty patients (34.5%) initiated early RRT after 24.1 ± 10.4 days from the onset and 6.4 ± 3.6 days from ICU admission. Thirty-four of 58 participants (58.6%) died during ICU follow-up. Univariate and multivariate Cox proportional-hazards model showed that early RRT was associated with a lower risk of all-cause mortality in ICU with an adjusted HR of 0.280 (95% CI: 0.106–0.738, p = 0.010). Sudden unexpected death (SUD) was remarkably reduced in the early RRT group, compared with the control group (0.2 vs. 2.9 per 100 person-day, p = 0.02). Conclusion: Early RRT can reduce the all-cause in-hospital mortality, especially SUD in patients with severe COVID-19, but not improve multi-organ impairment or increase the risk of AKI. Early initiation of RRT merits an optional strategy in critically ill patients with COVID-19 (ChiCTR2000030773).

Delayed intubation is associated with mortality in patients with severe COVID-19: A single-centre observational study in Switzerland

IntroductionSwitzerland experienced two waves of COVID-19 in 2020, but with a different ICU admission and treatment management strategy. The timing of ICU admission and intubation remains a matter of debate in severe patients. The aim of our study was to describe the characteristics of ICU patients between two subsequent waves of COVID-19 who underwent a different management strategy and to assess whether the timing of intubation was associated with differences in mortality. Patients and methodsWe conducted a prospective observational study of all adult patients with acute respiratory failure due to COVID-19 who required intubation between the 9th of March 2020 and the 9th of January 2021 in the intensive care unit (ICU) at Geneva University Hospitals, Switzerland. ResultsTwo hundred twenty-three patients were intubated during the study period; 124 during the first wave, and 99 during the second wave. Patients admitted to the ICU during the second wave had a higher SAPS II severity score (52.5 vs. 60; p = 0.01). The time from hospital admission to intubation was significantly longer during the second compared to the first wave (4 days [IQR, 1-7] vs. 2 days [IQR, 0-4]; p < 0.01). All-cause ICU mortality was significantly higher during the second wave (42% vs. 23%; p < 0.01). In a multivariate analysis, the delay between hospital admission and intubation was significantly associated with ICU mortality (OR 3.25 [95% CI, 1.38-7.67]; p < 0.05). ConclusionsIn this observational study, delayed intubation was associated with increased mortality in patients with severe COVID-19. Further randomised controlled trials are needed.

Corticosteroid treatment and mortality in mechanically ventilated COVID-19-associated acute respiratory distress syndrome (ARDS) patients: a multicentre cohort study

BackgroundSome unanswered questions persist regarding the effectiveness of corticosteroids for severe coronavirus disease 2019 (COVID-19) patients. We aimed to assess the clinical effect of corticosteroids on intensive care unit (ICU) mortality among mechanically ventilated COVID-19-associated acute respiratory distress syndrome (ARDS) patients.MethodsThis was a retrospective study of prospectively collected data conducted in 70 ICUs (68 Spanish, one Andorran, one Irish), including mechanically ventilated COVID-19-associated ARDS patients admitted between February 6 and September 20, 2020. Individuals who received corticosteroids for refractory shock were excluded. Patients exposed to corticosteroids at admission were matched with patients without corticosteroids through propensity score matching. Primary outcome was all-cause ICU mortality. Secondary outcomes were to compare in-hospital mortality, ventilator-free days at 28 days, respiratory superinfection and length of stay between patients with corticosteroids and those without corticosteroids. We performed survival analysis accounting for competing risks and subgroup sensitivity analysis.ResultsWe included 1835 mechanically ventilated COVID-19-associated ARDS, of whom 1117 (60.9%) received corticosteroids. After propensity score matching, ICU mortality did not differ between patients treated with corticosteroids and untreated patients (33.8% vs. 30.9%; p = 0.28). In survival analysis, corticosteroid treatment at ICU admission was associated with short-term survival benefit (HR 0.53; 95% CI 0.39–0.72), although beyond the 17th day of admission, this effect switched and there was an increased ICU mortality (long-term HR 1.68; 95% CI 1.16–2.45). The sensitivity analysis reinforced the results. Subgroups of age < 60 years, severe ARDS and corticosteroids plus tocilizumab could have greatest benefit from corticosteroids as short-term decreased ICU mortality without long-term negative effects were observed. Larger length of stay was observed with corticosteroids among non-survivors both in the ICU and in hospital. There were no significant differences for the remaining secondary outcomes.ConclusionsOur results suggest that corticosteroid treatment for mechanically ventilated COVID-19-associated ARDS had a biphasic time-dependent effect on ICU mortality. Specific subgroups showed clear effect on improving survival with corticosteroid use. Therefore, further research is required to identify treatment-responsive subgroups among the mechanically ventilated COVID-19-associated ARDS patients.

Comparison of mortality risk evaluation tools efficacy in critically ill COVID-19 patients

BackgroundAs the COVID-19 pandemic continues, the number of patients admitted to the intensive care unit (ICU) is still increasing. The aim of our article is to estimate which of the conventional ICU mortality risk scores is the most accurate at predicting mortality in COVID-19 patients and to determine how these scores can be used in combination with the 4C Mortality Score.MethodsThis was a retrospective study of critically ill COVID-19 patients treated in tertiary reference COVID-19 hospitals during the year 2020. The 4C Mortality Score was calculated upon admission to the hospital. The Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and Sequential Organ Failure Assessment (SOFA) scores were calculated upon admission to the ICU. Patients were divided into two groups: ICU survivors and ICU non-survivors.ResultsA total of 249 patients were included in the study, of which 63.1% were male. The average age of all patients was 61.32 ± 13.3 years. The all-cause ICU mortality ratio was 41.4% (n = 103). To determine the accuracy of the ICU mortality risk scores a ROC-AUC analysis was performed. The most accurate scale was the APACHE II, with an AUC value of 0.772 (95% CI 0.714–0.830; p < 0.001). All of the ICU risk scores and 4C Mortality Score were significant mortality predictors in the univariate regression analysis. The multivariate regression analysis was completed to elucidate which of the scores can be used in combination with the independent predictive value. In the final model, the APACHE II and 4C Mortality Score prevailed. For each point increase in the APACHE II, mortality risk increased by 1.155 (OR 1.155, 95% CI 1.085–1.229; p < 0.001), and for each point increase in the 4C Mortality Score, mortality risk increased by 1.191 (OR 1.191, 95% CI 1.086–1.306; p < 0.001), demonstrating the best overall calibration of the model.ConclusionsThe study demonstrated that the APACHE II had the best discrimination of mortality in ICU patients. Both the APACHE II and 4C Mortality Score independently predict mortality risk and can be used concomitantly.

Effect of Body Mass Index on the Clinical Outcomes of Adult Patients Treated With Venoarterial ECMO for Cardiogenic Shock

Current guidelines consider obesity to be a relative contraindication to venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. The authors investigated the effect of body mass index (BMI) on clinical outcomes in patients treated with VA-ECMO for cardiogenic shock. This was a retrospective and observational study. University hospital. The study comprised 150 adult patients who underwent VA-ECMO for cardiogenic shock. The primary outcome was intensive care unit (ICU) mortality. Of the 150 included patients, 10 were underweight (BMI < 18.5 kg/m²), 62 were normal weight (BMI=18.5-24.9 kg/m²), 34 were overweight (BMI=25.0-29.9 kg/m²), 34 were obese class I (BMI=30.0-34.9 kg/m²), and 10 were obese class II (BMI=35.0-39.9 kg/m²). All-cause ICU mortality was 62% (underweight, 70%; normal weight, 53%; overweight, 65%; class I obese, 71%; class II obese, 70%). After multivariate logistic regression, BMI was not associated with ICU mortality (adjusted odds ratio [aOR] 0.99 [0.92-1.07], p=0.8). Analysis by BMI category showed unfavorable mortality trends in underweight patients (aOR 3.58 [0.82-19.6], p=0.11) and class I obese patients (aOR 2.39 [0.95-6.38], p=0.07). No statistically significant differences were found among BMI categories in the incidences of complications. The results suggested that BMI alone should not be considered an exclusion criterion for VA-ECMO. The unfavorable trend observed in underweight patients could be the result of malnutrition.

Stratified outcomes of "Kidney Disease: Improving Global Outcomes" serum creatinine criteria in critical ill patients: a secondary analysis of a multicenter prospective study

To investigate the different outcomes of two types of acute kidney injury (AKI) according to standard of Kidney Disease: Improving Global Outcomes-AKI (KDIGO-AKI), and to analyze the risk factors that affect the prognosis of intensive care unit (ICU) patients in China. A secondary analysis was performed on the database of a previous study conducted by China Critical Care Clinical Trial Group (CCCCTG), which was a multicenter prospective study involving 3 063 patients in 22 tertiary ICUs in 19 provinces and autonomous regions of China. The demographic data, scores reflecting severity of illness, laboratory findings, intervention during ICU stay were extracted. All patients were divided into pure AKI (PAKI) and acute on chronic kidney disease (AoCKD). PAKI was defined as meeting the serum creatinine (SCr) standard of KDIGO-AKI (KDIGO-AKISCr) and the estimated glomerular filtration rate (eGFR) at baseline was ≥ 60 mL×min-1×1.73 m-2, and AoCKD was defined as meeting the KDIGO-AKISCr standard and baseline eGFR was 15-59 mL×min-1×1.73 m-2. All-cause mortality in ICU within 28 days was the primary outcome, while the length of ICU stay and renal replacement therapy (RRT) were the secondary outcome. The differences in baseline data and outcomes between the two groups were compared. The cumulative survival rate of ICU within 28 days was analyzed by Kaplan-Meier survival curve, and the risk factors of ICU death within 28 days were screened by Cox multivariate analysis. Of the 3 063 patients, 1 042 were enrolled, 345 with AKI, 697 without AKI. The AKI incidence was 33.11%, while ICU mortality within 28 days of AKI patients was 13.91% (48/345). Compared with PAKI patients (n = 322), AoCKD patients (n = 23) were older [years old: 74 (59, 77) vs. 58 (41, 72)] and more critical when entering ICU [acute physiology and chronic health evaluation II (APACHE II) score: 23 (19, 27) vs. 15 (11, 22)], had worse basic renal function [eGFR (mL×min-1×1.73 m-2): 49 (38, 54) vs. 115 (94, 136)], more basic complications [Charlson comorbidity index (CCI): 3 (2, 4) vs. 0 (0, 1)] and higher SCr during ICU stay [peak SCr for diagnosis of AKI (μmol/L): 412 (280, 515) vs. 176 (124, 340), all P < 0.01]. The mortality and RRT incidence within 28 days in ICU of AoCKD patients were significantly higher than those of PAKI patients [39.13% (9/23) vs. 12.11% (39/322), 26.09% (6/23) vs. 4.04% (13/322), both P < 0.01], while no significant difference was found in the length of ICU stay. Kaplan-Meier survival curve analysis showed that the 28-day cumulative survival rate in ICU in AoCKD patients was significantly lower than PAKI patients (Log-Rank: χ 2 = 5.939, P = 0.015). Multivariate Cox regression analysis showed that admission to ICU due to respiratory failure [hazard ratio (HR) = 4.458, 95% confidence interval (95%CI) was 1.141-17.413, P = 0.032], vasoactive agents treatment in ICU (HR = 5.181, 95%CI was 2.033-13.199, P = 0.001), and AoCKD (HR = 5.377, 95%CI was 1.303-22.186, P = 0.020) were independent risk factors for ICU death within 28 days. Further detailed classification (PAKI, AoCKD) based on KDIGO-AKISCr standard combined with eGFR is related to ICU mortality in critical patients within 28 days.

Prognostic factors associated with mortality in mechanically ventilated patients in the intensive care unit: A single-center, retrospective cohort study of 905 patients.

Data on outcomes of patients receiving mechanical ventilation (MV) in China are scarce.To investigate factors associated with the prognosis of patients given MV in the intensive care unit (ICU).A 12-year (January 1, 2006–December 31, 2017) retrospective cohort study.ICU of Beijing Geriatric Hospital, China.A total of 905 patients aged ≥16 years given MV during the study period.None.Among 905 patients included (610 men; median age, 78 years; Acute Physiology and Chronic Health Evaluation [APACHE]-II score, 27.3 ± 8.9), 585 survived (388 men; median age, 77 years; average APACHE-II score, 25.6 ± 8.4), and 320 died in the ICU (222 men; median age, 78 years; APACHE-II score, 30.6 ± 8.9). All-cause ICU mortality was 35.4%. In patients aged <65 years, factors associated with ICU mortality were APACHE-II score (odds ratio [OR], 1.108; 95% confidence interval [95% CI], 1.021–1.202; P = .014), nosocomial infection (OR, 6.618; 95% CI, 1.065–41.113; P = .043), acute kidney injury (OR, 17.302; 95% CI, 2.728–109.735; P = .002), invasive hemodynamic monitoring (OR, 10.051; 95% CI, 1.362–74.191; P = .024), MV for cardiopulmonary resuscitation (OR, 0.122; 95% CI, 0.016–0.924; P = .042), duration of MV (OR, 0.993; 95% CI, 0.988–0.998; P = .008), successful weaning from MV (OR, 0.012; 95% CI, 0.002–0.066; P < .001), and renal replacement therapy (OR, 0.039; 95% CI, 0.005–0.324; P = .003). In patients aged ≥65 years, factors associated with mortality were APACHE-II score (OR, 1.062; 95% CI, 1.030–1.096; P < .001), nosocomial infection (OR, 2.427; 95% CI, 1.359–4.334; P = .003), septic shock (OR, 2.017; 95% CI, 1.153–3.529; P = .014), blood transfusion (OR, 1.939; 95% CI, 1.174–3.202; P = .010), duration of MV (OR, 0.999; 95% CI, 0.999–1.000; P = .043), and successful weaning from MV (OR, 0.027; 95% CI, 0.015–0.047; P < .001).APACHE-II score, successful weaning, and nosocomial infection in the ICU are independently associated with the prognosis of patients given MV in the ICU.

Independent risk factors for ICU mortality after left ventricular assist device implantation.

Left ventricular assist devices (LVADs) are used as an alternative therapy for heart transplantation in patients with advanced heart failure. However, the mortality rate of these patients remains relatively high. A large proportion of deaths after LVAD implantation occur during intensive care unit (ICU) stay. We conducted a retrospective study to identify the risk factors for all-cause ICU mortality in patients with an implanted LVAD. Between January 1, 2008 and December 31, 2016, 70 consecutive patients who had received an LVAD were analyzed. The median ICU length of stay was 14days (IQR: 8-31) and 16 patients (22.9% [95%CI: 13.1-32.7]) died in the ICU. The 90-day mortality rate was 25.7% (95%CI: 15.5-35.9). The main causes of ICU mortality were: multiple organ failure, stroke, and hemorrhagic events. The univariate analysis identified the following perioperative risk factors for all-cause ICU mortality: hypertension, preoperative platelet count, preoperative white cell count, inotropic support before LVAD implantation, mechanical ventilation before LVAD implantation, renal replacement therapy before LVAD implantation, short-term mechanical support before LVAD implantation, INTERMACS class 1 to 2, low intraoperative platelet count, low early postoperative hemoglobin level, low early postoperative platelet count, low early postoperative pH, and massive perioperative blood transfusion. In the multivariate logistic regression analysis, only mechanical ventilation before LVAD implantation was retained as an independent risk factor for ICU mortality (OR=11.96 [95%CI: 2.67-53.45], P<.01). These findings confirm that most deaths after LVAD implantation occur in the ICU. Patients that receive mechanical ventilation preoperatively have the highest risk of death. This confirms the need to actively treat respiratory failure and to wean patients from respiratory support before LVAD implantation. Such a strategy offers the best opportunity to initiate active rehabilitation.

Association between aspirin therapy and the outcome in critically ill patients: a nested cohort study.

BackgroundAntiplatelet therapy may attenuate the undesirable effects of platelets on the inflammatory cascades in critical illness. The objective of this study was to evaluate the association between aspirin therapy during intensive care unit (ICU) stay and all-cause mortality.MethodsThis was a nested cohort study within two randomized controlled trials in which all enrolled patients (N = 763) were grouped according to aspirin intake during ICU stay. The primary endpoints were all-cause ICU mortality and hospital mortality. Secondary endpoints included the development of severe sepsis during the ICU stay, ICU and hospital length of stay and the duration of mechanical ventilation. Propensity score was used to adjust for clinically and statistically relevant variables.ResultsOf the 763 patients, 154 patients (20 %) received aspirin. Aspirin therapy was not associated with a reduction in ICU mortality (adjusted OR 1.18, 95 % CI 0.69–2.02, P = 0.55) nor with hospital mortality (adjusted OR 0.95, 95 % CI 0.61–1.50, P = 0.82). Aspirin use had no preferential association with mortality among any of the study subgroups. Additionally, aspirin therapy was associated with higher risk of ICU-acquired severe sepsis, and increased mechanical ventilation duration and ICU length of stay.ConclusionOur study showed that the use of aspirin in critically ill patients was not associated with lower mortality, but rather with an increased morbidity.Trial Registration NumberISRCTN07413772 and ISRCTN96294863.

Early fluid accumulation in children with shock and ICU mortality: a matched case-control study.

The purpose of this study was to evaluate the association between early fluid accumulation and mortality in children with shock states. We retrospectively reviewed children admitted in shock states to the pediatric intensive care unit (ICU) at a tertiary level children's hospital over a 7-month period. The study was designed as a matched case-control study. Children with early fluid overload, defined as fluid accumulation of ≥10% of admission body weight during the initial 3 days, were designated as the cases. They were compared with matched controls without early fluid accumulation. Cases and controls were matched for age, severity of illness at ICU admission and need for organ support. They were compared with respect to all-cause ICU mortality and other secondary outcomes. A total of 114 children (age range 0-17.4 years; N = 42 cases and 72 matched controls) met the study criteria. Mortality rate was 13% (15/114) in this cohort. Multivariable logistic regression analysis identified the presence of early fluid overload [adjusted odds ratio (OR) 9.17, 95% confidence interval (CI) 2.22-55.57], its severity (adjusted OR 1.11, 95% CI 1.05-1.19) and its duration (adjusted OR 1.61, 95% CI 1.21-2.28) as independent predictors of mortality. Cases had higher mortality than the controls (26 vs. 6 %; p 0.003), and this difference remained significant in the matched analysis (37 vs. 3%; p 0.002). The presence, severity and duration of early fluid are associated with increased ICU mortality in children admitted to the pediatric ICU in shock states.

A retrospective study on the effects of colistin therapy in children with multidrug-resistant Gram-negative bacterial pathogens: impact of HIV status on outcome

BackgroundNosocomially acquired multidrug-resistant (MDR) Gram-negative bacteria are important contributors to paediatric intensive care unit (PICU) mortality and morbidity, with limited treatment options.AimTo investigate the outcomes of all children treated with...

PTU-039 Mortality and utility of prognostic scoring models in cirrhotic patients admitted to a tertiary non-transplant intensive care unit (ICU) in the UK

IntroductionPatients with liver cirrhosis admitted to ICU have a poor prognosis with reported ICU, in-hospital and 1-year mortality rates of 37%>65%, 49–74% and 69–81% respectively. Prognostic models may enable accurate...