APACHE Score Research Articles

Pulse index contour continuous cardiac output (PICCO) monitoring in critically ill patients.

Objective: To evaluate the utility of Pulse index Contour Continuous Cardiac Output (PiCCO) monitoring in critically ill patients. Study Design: Cross-sectional study. Setting: Intensive Care Unti of Sindh Institute of Urology and Transplant, Karachi, Pakistan. Period: October 2022 to March 2023. Methods: Patients presenting with various types of shock, requiring high-dose vasopressors or inotropes, and not responding to initial fluid therapy were analyzed. Demographic details, SOFA score, APACHE score, and invasive hemodynamic parameters using the PiCCO system were documented. Results: Out of 142 ICU admissions, 38 patients were included in the study. Most patients were males (73%) with a median age of 39 years. Significant changes were observed in the cardiac index, cardiac performance index, global ejection fraction, and systemic vascular resistance index (SVRI), all with p-values less than 0.05. The interventions included the initiation of inotropes in 22 patients (57.8%), diuretics in 4 patients (10.5%), and intravenous fluids in 19 patients (50%). Additionally, vasopressor doses were adjusted in 18 patients (47.3%). Initially, patients were presumed to have pure septic shock based on CO2 gap, mixed venous saturation, and echocardiographic assessment. However, after applying PiCCO monitoring, the diagnosis was revised to mixed shock in 21 patients (55.2%). Conclusion: PiCCO monitoring appears to be a valuable tool in the ICU for managing patients with complex hemodynamic profiles, facilitating targeted interventions that lead to significant improvements in hemodynamic stability.

Pulmonary Events in ICU patients with hyperoxia: is it possible to relate arterial partial pressure of oxygen to coded diseases? A retrospective analysis

ObjectiveOxygen has been used liberally in ICUs for a long time to prevent hypoxia in ICU- patients. Current evidence suggests that paO2 >300 mmHg should be avoided, it remains uncertain whether an “optimal level” exists. We investigated how “mild” hyperoxia influences diseases and in-hospital mortality. DesignThis is a retrospective study. Setting112 mechanically ventilated ICU-patients were enrolled. Patients or participants112 ventilated patients were included and categorized into two groups based on the median paO2 values measured in initial 24 h of mechanical ventilation: normoxia group (paO2 ≤ 100 mmHg, n = 43) and hyperoxia group patients (paO2 > 100 mmHg, n = 69). InterventionsNo interventions were performed. Main variables of interestThe primary outcome was the incidence of pulmonary events, the secondary outcomes included the incidence of other new organ dysfunctions and in-hospital mortality. ResultsThe baseline characteristics, such as age, body mass index, lactate levels, and severity of disease scores, were similar in both groups. There were no statistically significant differences in the incidence of pulmonary events, infections, and new organ dysfunctions between the groups. 27 out of 69 patients (39.1%) in the “mild” hyperoxia group and 12 out of 43 patients (27.9%) in the normoxia group died during their ICU or hospital stay (p = 0.54). The mean APACHE Score was 29.4 (SD 7.9) in the normoxia group and 30.0 (SD 6.7) in the hyperoxia group (p = 0.62). ConclusionsWe found no differences in pulmonary events, other coded diseases, and in-hospital mortality between both groups. It remains still unclear what the "best oxygen regime" is for intensive care patients.

Treatment intensity, age and outcome in mechanical ventilated very old patients admitted to Intensive Care Unit.

The global population is aging, and the proportion of elderly patients admitted to Intensive Care Units (ICUs) is increasing. In this scenario, achieving a balance between judicious utilization of a limited and high-cost resource and providing optimal intensity of care presents a challenge, given that in very elderly patients, the value of ICU care is uncertain. The aim of our study is to evaluate the survival of older patients admitted to ICU who require mechanical ventilation (MV) at different levels of treatment intensity. A comprehensive longitudinal ICU database was retrospectively analyzed at a single tertiary center, from January 2008 to December 2014, of ICU subjects 80 years old or older who required mechanical ventilation. From January 2009 to December 2014, 482 subjects were admitted to the ICU and required mechanical ventilation. Among them, 376 (78%) were aged between 80 to 89 years, and 106 (22%) were aged 90 years or older, with a mean age of 85.84 (4.56). The mean APACHE II score was 21.53 (7.42), and the mean SOFA score was 5.75 (3.38). The total mortality during ICU admission was 46%, and the hospital mortality was 58%. Only age higher than 90 years (1.41(1.05;1.91), P = .02) and APACHE score (1.03(1.01;1.05), P < .001) were associated with mortality after adjustments. The TISS score was analyzed in tertiles and was not related to mortality in univariate analysis or after adjustments. Our data indicate that in older subjects using MV, higher intensity of treatment does not seem to translate into a survival benefit. This finding highlights the importance of considering individualized treatment plans for elderly patients in the ICU.

Iron metabolism indexes as predictors of the incidence of cardiac surgery-associated acute kidney surgery

BackgroundAcute kidney injury (AKI) is a major complication following cardiac surgery. We explored the clinical utility of iron metabolism indexes for identification of patients at risk for AKI after cardiac surgery.MethodsThis prospective observational study included patients who underwent cardiac surgery between March 2023 and June 2023. Iron metabolism indexes were measured upon admission to the intensive care unit. Multivariable logistic regression analyses were performed to explore the relationship between iron metabolism indexes and cardiac surgery-associated AKI (CSA-AKI). Receiver operating characteristic (ROC) curve was used to assess the predictive ability of iron, APACHE II score and the combination of the two indicators. Restricted cubic splines (RCS) was used to further confirm the linear relationship between iron and CSA-AKI.ResultsAmong the 112 recruited patients, 38 (33.9%) were diagnosed with AKI. Multivariable logistic regression analysis indicated that APACHE II score (odds ratio [OR], 1.208; 95% confidence interval [CI], 1.003–1.455, P = 0.036) and iron (OR 1.069; 95% CI 1.009–1.133, P = 0.036) could be used as independent risk factors to predict CSA-AKI. ROC curve analysis showed that iron (area under curve [AUC] = 0.669, 95% CI 0.572–0.757), APACHE II score (AUC = 0.655, 95% CI 0.557–0.744) and iron and APACHE II score combination (AUC = 0.726, 95% CI 0.632–0.807) were predictive indicators for CSA-AKI. RCS further confirmed the linear relationship between iron and CSA-AKI.ConclusionsElevated iron levels were independently associated with higher risk of CSA-AKI, and there was a linear relationship between iron and CSA-AKI.

Risk Factors Associated with Antibiotic Exposure Variability in Critically Ill Patients: A Systematic Review.

(1) Background: Knowledge about the behavior of antibiotics in critically ill patients has been increasing in recent years. Some studies have concluded that a high percentage may be outside the therapeutic range. The most likely cause of this is the pharmacokinetic variability of critically ill patients, but it is not clear which factors have the greatest impact. The aim of this systematic review is to identify risk factors among critically ill patients that may exhibit significant pharmacokinetic alterations, compromising treatment efficacy and safety. (2) Methods: The search included the PubMed, Web of Science, and Embase databases. (3) Results: We identified 246 observational studies and ten clinical trials. The most studied risk factors in the literature were renal function, weight, age, sex, and renal replacement therapy. Risk factors with the greatest impact included renal function, weight, renal replacement therapy, age, protein or albumin levels, and APACHE or SAPS scores. (4) Conclusions: The review allows us to identify which critically ill patients are at a higher risk of not reaching therapeutic targets and helps us to recognize the extensive number of risk factors that have been studied, guiding their inclusion in future studies. It is essential to continue researching, especially in real clinical practice and with clinical outcomes.

Can We Improve Mortality Prediction in Patients with Sepsis in the Emergency Department?

Background and Objectives: Sepsis represents a global health challenge and requires advanced diagnostic and prognostic approaches due to its elevated rate of morbidity and fatality. Our study aimed to assess the value of a novel set of six biomarkers combined with severity scores in predicting 28 day mortality among patients presenting with sepsis in the Emergency Department (ED). Materials and Methods: This single-center, observational, prospective cohort included sixty-seven consecutive patients with septic shock and sepsis enrolled from November 2020 to December 2022, categorized into survival and non-survival groups based on outcomes. The following were assessed: procalcitonin (PCT), soluble Triggering Receptor Expressed on Myeloid Cells-1 (sTREM-1), the soluble form of the urokinase plasminogen activator receptor (suPAR), high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and azurocidin 1 (AZU1), alongside clinical scores such as the Quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS), the Sequential Organ Failure Assessment (SOFA), the Acute Physiology and Chronic Health Evaluation II (APACHE II), the Simplified Acute Physiology Score II and III (SAPS II/III), the National Early Warning Score (NEWS), Mortality in Emergency Department Sepsis (MEDS), the Charlson Comorbidity Index (CCI), and the Glasgow Coma Scale (GCS). The ability of each biomarker and clinical score and their combinations to predict 28 day mortality were evaluated. Results: The overall mortality was 49.25%. Mechanical ventilation was associated with a higher mortality rate. The levels of IL-6 were significantly higher in the non-survival group and had higher AUC values compared to the other biomarkers. The GCS, SOFA, APACHEII, and SAPS II/III showed superior predictive ability. Combining IL-6 with suPAR, AZU1, and clinical scores SOFA, APACHE II, and SAPS II enhanced prediction accuracy compared with individual biomarkers. Conclusion: In our study, IL-6 and SAPS II/III were the most accurate predictors of 28 day mortality for sepsis patients in the ED.

Evaluating the Utility of Clinical Scores APACHE, CURB, SOFA, and NEWS2 at Admission and 5-Days after Symptom Onset in Predicting Severe COVID-19 in Patients with Diabetes.

The elevated risk of severe COVID-19 outcomes in patients with diabetes underscores the need for effective predictive tools. This study aimed to assess the predictive accuracy of APACHE II, CURB-65, SOFA, and NEWS2 scores at critical time points in diabetic patients diagnosed with COVID-19, aiming to guide early and potentially life-saving interventions. In a prospective cohort study conducted from January 2021 to December 2023, adult patients with type 1 or type 2 diabetes and confirmed SARS-CoV-2 infection were evaluated. Clinical scores were calculated at admission and five days post-symptom onset, with data analyzed using receiver operating characteristic (ROC) curves and logistic regression to determine areas under the curve (AUC) and hazard ratios (HR) for severe outcomes. Among the 141 diabetic patients studied, ROC analysis revealed high AUC values for SOFA (0.771 at admission, 0.873 at day five) and NEWS2 (0.892 at admission, 0.729 at day five), indicating strong predictive accuracy for these scores. The APACHE II score's AUC improved from 0.698 at admission to 0.806 on day five, reflecting worsening patient conditions. Regression analysis showed significant HRs associated with exceeding threshold scores: The SOFA score HR at day five was 3.07 (95% CI: 2.29-4.12, p < 0.001), indicating a threefold risk of severe outcomes. Similarly, the APACHE II score showed an HR of 2.96 (95% CI: 2.21-3.96, p < 0.001) at day five, highlighting its utility in predicting severe disease progression. The SOFA and NEWS2 scores demonstrated excellent early predictive accuracy for severe COVID-19 outcomes in diabetic patients, with significant AUC and HR findings. Continuous score monitoring, especially of APACHE II and SOFA, is crucial for managing and potentially mitigating severe complications in this vulnerable population. These tools can effectively assist in the timely escalation of care, thus potentially reducing morbidity and mortality among diabetic patients during the COVID-19 pandemic.

Intra-abdominal pressure: a predictor of severity in acute pancreatitis

Background: Acute pancreatitis is a multisystem disease which has an unpredictable course. The major consequence of severe acute pancreatitis is usually intra-abdominal hypertension. So, abdominal compartment syndrome occurs with serve increase in intra-abdominal pressure (IAP) with organ failure. If conservative measures fail, some early interventional procedures have to be performed to reduce mortality in those patients. Methods: The ethics committee clearance was obtained. The study included 50 patients who were admitted in our institution with acute pancreatitis (diagnosed based on clinical, radiological, biochemical parameters) from December 2022 to August 2023. Intravesical route was used to measure IAP and it was performed by bladder catheterization using a Foley's catheter which was then connected with a three-way stopcock, which further attached with a water manometer and on that same day APACHE scores was calculated, compared and analyzed. Results: IAP was &gt;25 cm H2O in 48% of patients and 28% of patients developed MODS and they did not survive. The mean IAP among the survivors was 13.56 cm H2O and in non-survivors it was 24.94 cm H2O. Correlation studies between IAP &amp; the clinical severity of acute pancreatitis was significant (p&lt;0.05). Conclusions: IAP seems to be a simple, reliable and single mortality predictor and helps to assess organ failure in acute pancreatitis and it also well correlates with other pancreatic prognostic scores. It also serves as a selective prognostic marker in acute pancreatitis and found to have a direct correlation between IAP and clinical severity of acute pancreatitis.

Association between Sick Euthyroid Syndrome and Poor Prognosis in Severe Burn Patient

Abstract Background Euthyroid sick syndrome (also known as non-thyroidal illness syndrome) can be described as abnormal findings on thyroid function tests that occur in the setting of a non-thyroidal illness (NTI), without preexisting hypothalamic-pituitary and thyroid gland dysfunction. After recovery from an NTI, these thyroid function test result abnormalities should be completely reversible, study of euthyroid sick syndrome in burn patients. Aim of the Work The aim of study is to examine the ability of Euthyroid sick syndrome in predicting prognosis in severe burn patients. Patients and Methods A case control study was conducted in burn ICU in Ain Shams University Hospitals from march 2022 to September 2022,88 patients were admitted to study with 44 burn case with ESS and 44 burn case without ESS according to inclusion and exclusion criteria. Results The results showed that the group with ESS are more associated with higher rate of morality, hospital stay and more poor prognosis with worse APACHE score levels compared to the burn group with ESS. The study showed that using APACHE score with T3 levels measurements are more accurate in detecting morality in burn ICU patient. Conclusion The study demonstrated that ESS are more associated with higher rate of morality, hospital stay and more poor prognosis with worse APACHE score levels.

Outcomes of different pulmonary rehabilitation protocols in patients under mechanical ventilation with difficult weaning: a retrospective cohort study

BackgroundThe endeavor of liberating patients from ventilator dependence within respiratory care centers (RCCs) poses considerable challenges. Multiple factors contribute to this process, yet establishing an effective regimen for pulmonary rehabilitation (PR) remains uncertain. This retrospective study aimed to evaluate existing rehabilitation protocols, ascertain associations between clinical factors and patient outcomes, and explore the influence of these protocols on the outcomes of the patients to shape suitable rehabilitation programs.MethodsConducted at a medical center in northern Taiwan, the retrospective study examined 320 newly admitted RCC patients between January 1, 2015, and December 31, 2017. Each patient received a tailored PR protocol, following which researchers evaluated weaning rates, RCC survival, and 3-month survival as outcome variables. Analyses scrutinized differences in baseline characteristics and prognoses among three PR protocols: protocol 1 (routine care), protocol 2 (routine care plus breathing training), and protocol 3 (routine care plus breathing and limb muscle training).ResultsAmong the patients, 28.75% followed protocol 1, 59.37% protocol 2, and 11.88% protocol 3. Variances in age, body-mass index, pneumonia diagnosis, do-not-resuscitate orders, Glasgow Coma Scale scores (≤ 14), and Acute Physiology and Chronic Health Evaluation II (APACHE) scores were notable across these protocols. Age, APACHE scores, and abnormal blood urea nitrogen levels (> 20 mg/dL) significantly correlated with outcomes—such as weaning, RCC survival, and 3-month survival. Elevated mean hemoglobin levels linked to increased weaning rates (p = 0.0065) and 3-month survival (p = 0.0102). Four adjusted models clarified the impact of rehabilitation protocols. Notably, the PR protocol 3 group exhibited significantly higher 3-month survival rates compared to protocol 1, with odds ratios (ORs) ranging from 3.87 to 3.97 across models. This association persisted when comparing with protocol 2, with ORs between 3.92 and 4.22.ConclusionOur study showed that distinct PR protocols significantly affected the outcomes of ventilator-dependent patients within RCCs. The study underlines the importance of tailored rehabilitation programs and identifies key clinical factors influencing patient outcomes. Recommendations advocate prospective studies with larger cohorts to comprehensively assess PR effects on RCC patients.

A retrospective study of the predictors of mortality among patients in intensive care units at North West-Bank hospitals in Palestine

ABSTRACT Objectives The intensive care unit (ICU) mortality rate remains high, especially in developing countries, regardless of the advances in critical management. There is a lack of studies about mortality causes in hospitals and particularly ICUs in Palestine. This study evaluated the demographic and clinical characteristics of critically ill patients and determined the predictors of mortality among patients in the ICU. Methods A retrospective study assessed all patients who stayed in the ICU for more than 24 h from January 2017 to January 2019. Data were collected from the patient’s files. Patient characteristics (background, clinical variables, and comorbidities) were recorded. Results The study included 227 eligible ICU patients. The cases’ mean age was 55.5 (SD ± 18.2) years. The overall ICU mortality rate was 31.7%. The following factors were associated with high adjusted mortality odds: admission from inside the hospital (adjusted odds ratio (aOR), 2.1, 95% CI: 1.1–3.9, p < 0.05), creatinine level ≥2 mg/dl on admission (aOR, 2.7, 95% CI: 1.3–5.8, p < 0.01), hematology malignancy patients (aOR, 3.4, 95% CI: 1.6–6.7, p = 0.001), immune-compromised (aOR, 2.5, 95% CI: 1.3–4.7, p < 0.01), septic shock (aOR, 27.1, 95% CI: 7.9–88.3, p < 0.001), hospital-acquired infections (aOR: 13.4, 95% CI: 4.1–57.1, p < 0.001), and patients with multiple-source infection (aOR: 16.3, 95% CI: 6.4–57.1, p < 0.001). Also, high SOFA and APACHE scores predicted morality (p < 0.001). Conclusion The mortality rate among ICU patients was high. It was higher among those admitted from the hospital wards, septic shock, hospital-acquired infection, multiple infection sources, and multi-drug resistance infections. Thus, strategies should be developed to enhance the ICU environment and provide sufficient resources to minimize the effects of these predictors.

Pulmonary Events in ICU patients with hyperoxia: is it possible to relate arterial partial pressure of oxygen to coded diseases? A retrospective analysis

ObjectiveOxygen has been used liberally in ICUs for a long time to prevent hypoxia in ICU- patients. Current evidence suggests that paO2 >300 mmHg should be avoided, it remains uncertain whether an “optimal level” exists. We investigated how “mild” hyperoxia influences diseases and in-hospital mortality. DesignThis is a retrospective study. Setting112 mechanically ventilated ICU-patients were enrolled. Patients or participants112 ventilated patients were included and categorized into two groups based on the median paO2 values measured in initial 24 h of mechanical ventilation: normoxia group (paO2 ≤ 100 mmHg, n = 43) and hyperoxia group patients (paO2 > 100 mmHg, n = 69). InterventionsNo interventions were performed. Main variables of interestThe primary outcome was the incidence of pulmonary events, the secondary outcomes included the incidence of other new organ dysfunctions and in-hospital mortality. ResultsThe baseline characteristics, such as age, body mass index, lactate levels, and severity of disease scores, were similar in both groups. There were no statistically significant differences in the incidence of pulmonary events, infections, and new organ dysfunctions between the groups. 27 out of 69 patients (39.1%) in the “mild” hyperoxia group and 12 out of 43 patients (27.9%) in the normoxia group died during their ICU or hospital stay (p = 0.54). The mean APACHE Score was 29.4 (SD 7.9) in the normoxia group and 30.0 (SD 6.7) in the hyperoxia group (p = 0.62). ConclusionsWe found no differences in pulmonary events, other coded diseases, and in-hospital mortality between both groups. It remains still unclear what the "best oxygen regime" is for intensive care patients.

Antimicrobial resistance in intensive care patients hospitalized with SEPSIS: a comparison between the COVID-19 pandemic and pre-pandemic era.

Coronavirus disease 2019 (COVID-19) is a highly contagious viral illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has had a dramatic effect on the world, resulting in millions of deaths worldwide and causing drastic changes in daily life. A study reported that septic complications were associated with high mortality in COVID-19 patients. This study aimed to evaluate how the COVID-19 pandemic changed the pre-pandemic and post-pandemic prevalence of sepsis in ICUs and to evaluate the different risk factors associated with mortality and the different diffusion of microorganisms and their resistance. We conducted a single-center retrospective observational clinical study, observing all patients in the ICU of the SS Annunziata Hospital in Chieti (Italy) who were diagnosed with sepsis and had a bacterial isolate from their blood culture. Sepsis was diagnosed by SEPSIIS III criteria. We enrolled all in-patients in the ICU from January 2018 to December 2021. We divided the patients into three groups: (1) non-pandemic period (Np) hospitalized in 2018-2019, (2) pandemic period (Pp)-COVID hospitalized in 2020-2021 with a diagnosis of COVID-19, and (3) Pp-non-COVID patients hospitalized in 2020-2021 without a diagnosis of COVID-19. From January 2018 to December 2021, 1,559 patients were admitted to the ICU, of which 211 patients [36 (17.1%) in 2018, 52 (24.6%) in 2019, 73 (34.6%) in 2020, and 50 (23.7%) in 2021, respectively] met the selection criteria: 88 patients in period Np, 67 patients in Pp without COVID-19, and 56 patients Pp with COVID-19. The overall mortality of these patients was high (65.9% at 30 days in Np), but decreased during the Pp (60.9%): Pp-non-COVID was 56.7% vs. Pp-COVID 66.1%, with a statistically significant association with APACHE III score (OR 1.08, 95%CI 1.04-1.12, p < 0.001), SOFA score (OR 1.12, 95%CI 1.03-1.22, p = 0.004), and age (OR 1.04, 95%CI 1.02-1.07, p < 0.0001). Between the Np vs. Pp periods, we observed an increase in a few Gram-positive bacteria such as S. capitis (1 pt. -0.9% vs. 14 pt. -7.65%- p = 0.008), S. epidermidis, Streptococcus spp., and E. faecalis, as well as a decrease in a case of blood culture positive for S. aureus, S. hominis, and E. faecium. In Gram-negative bacteria, we observed an increase in cases of Acinetobacter spp. (Np 6 pt. -5.1%- vs. Pp 20 pt. -10.9%, p = 0.082), and Serratia spp., while cases of sepsis decreased from E. faecium (Np 11 pt. -9.4%- vs. Pp 7 pt. -3.8%, p = 0.047), and Enterobacter spp., S. haemolyticus, S. maltophilia, Proteus spp., and P. aeruginosa have not changed. Finally, we found that resistance to OXA-48 (p = 0.040), ESBL (p = 0.002), carbapenems (p = 0.050), and colistin (p = 0.003) decreased with time from Np to Pp, particularly in Pp-COVID. This study demonstrated how the COVID-19 pandemic changed the prevalence of sepsis in the ICU. It emerged that the risk factors associated with mortality were APACHE and SOFA scores, age, and, above all, the presence of ESBL-producing bacteria. Despite this, during the pandemic phase, we have observed a significant reduction in the emergence of resistant germs compared to the pre-pandemic phase.

Outcome of Cancer Patients with an Unplanned Intensive Care Unit Admission: Predictors of Mortality and Long-term Survival.

Understanding the characteristics and outcomes of cancer patients with unplanned ICU admission is imperative for therapeutic decisions and prognostication purposes. To describe the clinical characteristics of patients with hematological and non-hematological malignancies (NHM) who require unplanned ICU admission and to determine the predictors of mortality and long-term survival. This retrospective study included all patients with cancer who had an unplanned ICU admission between 2011 and 2016 at a tertiary hospital in Saudi Arabia. The following variables were collected: age, gender, ICU length of stay (LOS), APACHE II score, type of malignancy, febrile neutropenia, source and time of admission, and need for mechanical ventilation (MV), renal replacement therapy (RRT), and treatment with vasopressors (VP). Predictors of mortality and survival rates at 28 days and 3, 6, and 12 months were calculated. The study included 410 cancer patients with 466 unplanned ICU admissions. Of these, 52% had NHM. The average LOS in the ICU was 9.6 days and the mean APACHE score was 21.9. MV was needed in 73% of the patients, RRT in 15%, and VP in 24%, while febrile neutropenia was present in 24%. There were statistically significant differences between survivors and non-survivors in the APACHE II score (17.7 ± 8.0 vs. 25.6 ± 9.2), MV use (52% vs. 92%), need for RRT (6% vs. 23%), VP use (42% vs. 85%), and presence of febrile neutropenia (18% vs. 30%). The predictors of mortality were need for MV (OR = 4.97), VP (OR = 3.43), RRT (OR = 3.31), and APACHE II score (OR = 1.10). Survival rates at 28 days, 3, 6, and 12 months were 52%, 28%, 22%, and 15%, respectively. The survival rate of cancer patients with an unplanned admission to the ICU remains low. Predictors of mortality include need for MV, RRT, and VP and presence of febrile neutropenia. About 85% of cancer patients died within 1 year after ICU admission.

Tocilizumab treatment in COVID-19 patients: therapy's side effects and effect on mortality.

This study aimed to determine the effect of tocilizumab use on mortality and the potential side effects in COVID-19 patients. The intensive care patients were divided into the tocilizumab group and the control group. Hemogram, biochemistry, acute phase reactant values, age, gender, comorbidity, and culture results were recorded on the 0th, 3rd, 7th, and 14th days. Factors affecting mortality between and within the groups and side effects were examined. 32.14% of the patients were female, and 67.85% were male. The tocilizumab group had high alanine aminotransferase and potassium on day 3. On day 7, low levels of platelet, glucose, international normalized ratio, prothrombin time, and active partial thromboplastin time levels were observed. Procalcitonin, C-reactive protein, and fibrinogen levels were low on days 3 and 7. The relationship between the tocilizumab treatment and mortality was statistically not significant, although the APACHE score was low. In the tocilizumab group, the presence of additional disease and reproduction in culture significantly increased mortality. Despite the risks of side effects, tocilizumab was used in COVID-19 treatment since it is an interleukin-6 blocker. Although the first publications stated that the treatment could decrease the mortality rate, later meta-analyses did not support these results. Our study also found that using tocilizumab did not make a difference in long-term mortality. We also observed that the known side effects were seen in short-term use.

Association of obesity on the outcome of critically ill patients affected by COVID-19

ObjectiveTo evaluate the impact of obesity on ICU mortality. DesignObservational, retrospective, multicentre study. SettingIntensive Care Unit (ICU). PatientsAdults patients admitted with COVID-19 and respiratory failure. InterventionsNone. Primary variables of interestCollected data included demographic and clinical characteristics, comorbidities, laboratory tests and ICU outcomes. Body mass index (BMI) impact on ICU mortality was studied as (1) a continuous variable, (2) a categorical variable obesity/non-obesity, and (3) as categories defined a priori: underweight, normal, overweight, obesity and Class III obesity. The impact of obesity on mortality was assessed by multiple logistic regression and Smooth Restricted cubic (SRC) splines for Cox hazard regression. Results5,206 patients were included, 20 patients (0.4%) as underweight, 887(17.0%) as normal, 2390(46%) as overweight, 1672(32.1) as obese and 237(4.5%) as class III obesity. The obesity group patients (n = 1909) were younger (61 vs. 65 years, p < 0.001) and with lower severity scores APACHE II (13 [9–17] vs. 13[10−17, p < 0.01) than non-obese. Overall ICU mortality was 28.5% and not different for obese (28.9%) or non-obese (28.3%, p = 0.65). Only Class III obesity (OR = 2.19, 95%CI 1.44–3.34) was associated with ICU mortality in the multivariate and SRC analysis. ConclusionsCOVID-19 patients with a BMI > 40 are at high risk of poor outcomes in the ICU. An effective vaccination schedule and prolonged social distancing should be recommended.

Predictors of Treatment Failure and Mortality among Patients with Septic Shock Treated with Meropenem in the Intensive Care Unit.

The aim of the study was to determine the predictors of meropenem treatment failure and mortality in the Intensive Care Unit (ICU). This was a retrospective study, involving sepsis and septic shock patients who were admitted to the ICU and received intravenous meropenem. Treatment failure is defined as evidence of non-resolved fever, non-reduced total white cell (TWC), non-reduced C-reactive protein (CRP), subsequent culture negative and death in ICU. An Acute Physiology and Chronic Health Evaluation II (APACHE II) and duration of antibiotic treatment less than 5 days were associated with treatment failure with adjusted OR = 1.24 (95% CI: 1.15, 1.33; P < 0.001), OR = 65.43 (95% CI: 21.70, 197.23; P < 0.001). A higher risk of mortality was observed with higher APACHE and Sequential Organ Failure Assessment (SOFA) scores, initiating antibiotics > 72 h of sepsis, duration of antibiotic treatment less than 5 days and meropenem with renal adjustment dose with an adjusted OR = 1.21 (95% CI: 1.12, 1.30; P < 0.001), adjusted OR = 1.23 (95% CI: 1.08, 1.41; P < 0.001), adjusted OR = 6.38 (95% CI: 1.67, 24.50; P = 0.007), adjusted OR = 0.03 (95% CI: 0.01, 0.14; P < 0.001), adjusted OR = 0.30 (95% CI: 0.14, 0.64; P = 0.002). A total of 50 (14.12%) patients had a treatment failure with meropenem with 120 (48.02%) ICU mortality. The predictors of meropenem failure are higher APACHE score and shorter duration of meropenem treatment. The high APACHE, high SOFA score, initiating antibiotics more than 72 h of sepsis, shorter duration of treatment and meropenem with renal adjustment dose were predictors of mortality.

Extracorporeal Methods of Hemocorrection in Patients with Abdominal Sepsis

BACKGROUND. Theoretical data convincingly support the use of extracorporeal hemocorrection (ECHC) methods in the treatment of sepsis. However, a large number of researchers have still not been able to convincingly prove the advantage of ECHC methods; there is no unanimity of opinion. We tried to analyze our own experience in using ECHC methods in the treatment of abdominal sepsis over the past 3 years. AIM OF STUDY. To analyze the use of ECHC methods in the early stages of treatment of abdominal sepsis, to determine whether their use had an advantage for survival. STUDY DESIGN. Prospective cohort. DESCRIPTION OF THE METHOD. In 50 cases (group 1), ECHC was performed early after surgery. The median time from admission to the intensive care unit after surgery to the start of ECHC was 25.3 (17.7; 36.5) hours. When determining the ECHC modality, we were guided by the individual approach and clinical experience of the ECHC specialist. Apheresis methods alone were performed in 8 % of patients (4/50), a combination of apheresis methods and renal replacement therapy was performed in 40 % (20/50), renal replacement therapy (RRT) methods were performed in 98 % (46/50), plasmapheresis/plasma exchange/selective plasma filtration were performed in 30 % (15/50), selective hemosorption of cytokines was performed in 4 % (2/50), selective hemosorption lipopolysaccharides was performed in 24 % (12/50). We analyzed outcomes, assessments of the severity of functional disorders and sepsis-associated organ dysfunction according to the APACHE scales II and SOFA and their dynamics, probabilities of outcomes depending on the scores on the indices (logistic regression); life times, cumulative survival rate (Kaplan-Meier method). SAMPLE CHARACTERISTICS. There were 113 patients after emergency laparotomy due to widespread peritonitis, abdominal sepsis, aged from 23 to 90 years. 67 men, 46 women. In 50 cases of observation (group 1), ECHC was performed in the early stages ; in 63 cases, methods of active hemocorrection were not used (group 2). In group 1 there were 35 patients with septic shock and 15 patients with stable hemodynamics (subgroup 1/shock and subgroup 1/sepsis). In group 2 there were 20 patients with shock and 43 with stable hemodynamics (subgroup 2/shock and subgroup 2/sepsis). RESEARCH RESULTS ECHC. Methods allowed survival of patients with more severe APACHE scores II and SOFA: in survivors in subgroup 1/shock Me 29 (24; 31) versus 23 (14; 26) in the subgroup 2/shock and 8 (4; 10) versus 4 (2; 6) points, p=0.048 and p = 0.010; with stable hemodynamics in survivors in subgroup 1/sepsis Me 20 (17; 22) versus 15 (11; 19) in subgroup 2/sepsis, p=0.016. ECHC changed the survival threshold in favor of more severe patients from 29 to 33 points; reduced the likelihood of an unfavorable outcome 1.2-fold for each point on the APACHE scale II and 1,276 times over the entire range of estimates; prolonged survival time in hemodynamically unstable patients at a significance level of p = 0.083, shifting the first quartile of survival from 1 to 12 days, the median from 12 to 20, the third quartile from 27 to 45 days. When performing ECHC, the cumulative survival rate was higher throughout the entire hospital observation period: 0.886 (95 % CI 0.780–0.939) in 2 days versus 0.700 (95 % CI 0.499–0.802); 0.800 (95 % CI 0.667–0.868) in 10 days versus 0.545 (95 % CI 0.325–0.658); 0.653 (95 % CI 0.494–0.734) in 14 days versus 0.416 (95 % CI 1.185–0.533). Overall mortality from all causes was 35.4 % (40/113), 67.3 (37/55) with shock, 5.2 % (3/58) with stable hemodynamics. The maximum risk of an unfavorable outcome occurred in the early stages: 30 % (12/40) of all deaths occurred in the first 4 days after surgery, 20 % (8/40) in the first 24 hours. In shock patients, 10-day mortality was lower when performing ECHC: 20.0 % (7/35) versus 45.0 % (9/20), p = 0.050, 1st stage. Fisher’s test, P = 0.38 insufficient. Hospital mortality in the shock subgroups was equal, all the advantages of ECHC achieved in the early stages were lost; although in most late outcomes the peritonitis was relieved; which was confirmed during the section. CONCLUSIONS. The power of the study was sufficient to identify statistically significant advantages of extracorporeal hemocorrection in the treatment of abdominal sepsis based on APACHE index estimates II and SOFA. For the Kaplan–Meier method, differences were obtained for shock patients at a significance level of 0.083; the number of observations must be doubled to detect statistically significant differences. The final results of hospital mortality require additional in-depth analysis, since in the later stages many deaths were not associated with abdominal sepsis and occurred with already resolved peritonitis. It is necessary to understand to what extent they were associated with experienced sepsis, and to what extent with comorbid pathology; whether there was an association with methods of extracorporeal hemocorrection.

Association between the levels of urinary cell cycle biomarkers and non-recovery of renal function among critically ill geriatric patients with acute kidney injury

The lack of early renal function recovery among geriatric patients with acute kidney injury (AKI) in the intensive care unit (ICU) is a commonly observed and acknowledged poor prognostic factor, especially for older adults. However, no reliable prognostic biomarker is available for identifying individuals at risk of renal non-recovery or mortality in older adults. In this prospective observational cohort study, we enrolled critically ill older adults (aged ≥ 60 years) with AKI from the ICU and followed their disease progression. The primary endpoint was renal non-recovery within seven days of follow-up, while the secondary endpoint was the determinants of 30-day mortality after AKI. We assessed the predictive accuracy using receiver operating characteristic curves and performed between-group comparisons using the log-rank test. Among 209 older adults, 117 (56.0%) experienced renal recovery. Multiple regression analysis revealed that urine levels of tissue inhibitor of metalloproteinase-2 (TIMP-2) multiplied by insulin-like growth factor-binding protein 7 (IGFBP7) ([TIMP-2]*[IGFBP7]), AKI stages 2–3, and the Acute Physiology and Chronic Health Evaluation (APACHE II) score were independently associated with renal non-recovery. The regression model incorporating [TIMP-2]*[IGFBP7] demonstrated a fair predictive value (AUC 0.774, p < 0.001), with the optimal threshold set at 0.81 (ng/mL)2/1000. When [TIMP-2]*[IGFBP7] was combined with AKI severity and the APACHE score, the AUC increased to 0.851. In conclusion, urine [TIMP-2]*[IGFBP7] is a reliable biomarker associated with renal non-recovery in critically ill older adults, and its predictive efficacy can be further enhanced when combined with AKI severity and the APACHE score.

Comparison of Critical Illness Score in Patients Admitted to Intermediate Care Units of a Tertiary Care Hospital: A Comparative Cross-Sectional Study from Karachi, Pakistan.

Intermediate care units (IMCUs) serve as step-up units for emergency department patients and as step-down units for critically ill patients transferred from intensive care units. This study compares four critical illness scores for assessment of acutely ill patients and their accuracy in predicting mortality in patients admitted to IMCU. A comparative cross-sectional study on patients aged ≥18 admitted to IMCU of Aga Khan University Hospital from 2017 to 2019. All patients admitted to IMCU from the emergency room were included in the study. Patient's record were reviewed for demographic data, physiological and laboratory parameters. Critical illness scores were calculated from these variables for each patient. A total of 1192 patients were admitted to the IMCU, of which 923 (77.4%) medical records were finally analyzed. The mean (SD) age of participants was 62 years (± 16.5) and 469 (50.8%) were women. The overall hospital mortality rate of patients managed in IMCU was 6.4% (59/923 patients). The median scores of APACHE II, SOFA, SAPS II and MEWS were 16 (IQR 11-21), 4 (IQR 2-6), 36 (IQR 30-53) and 3 (IQR 2-4) points respectively. AUC for SAPS II was 0.763 (95% CI: 0.71-0.81), SOFA score was 0.735 (95% CI: 0.68-0.79) and MEWS score was 0.714 (95% CI: 0.66-0.77). The lowest ROC curve was 0.584 (95% CI: 0.52-0.64) for APACHE II. In conclusion, our study found that SAPS II, followed by SOFA and MEWS scores, provided better discrimination in stratifying critical illness in patients admitted to IMCU of a tertiary care hospital in Pakistan.