APACHEII Score Research Articles

A NOMOGRAM FOR PREDICTING PATIENTS WITH SEVERE HEATSTROKE.

Background: No predictive models are currently available to predict poor prognosis in patients with severe heatstroke. We aimed to establish a predictive model to help clinicians identify the risk of death and customize individualized treatment. Methods: The medical records and data of 115 patients with severe heatstroke hospitalized in the intensive care unit of Changzhou No. 2 People's Hospital between June 2013 and September 2019 were retrospectively analyzed for modeling. Furthermore, data of 84 patients with severe heatstroke treated at Jintan No. 1 People's Hospital from June 2013 to 2021 were retrospectively analyzed for external verification of the model. We analyzed the hematological parameters of the patients recorded within 24 h of admission, which included routine blood tests, liver function, renal function, coagulation routine, and myocardial enzyme levels. Risk factors related to death in patients with severe heatstroke were screened using Least Absolute Shrinkage and Selection Operator regression. The independent variable risk ratio for death was investigated using the Cox univariate and multivariate regression analyses. The nomogram was subsequently used to establish a suitable prediction model. A receiver operating characteristic curve was drawn to evaluate the predictive power of the prediction model and the Acute Physiology and Chronic Health Evaluation (APACHE II) score. In addition, decision curve analysis was established to assess the clinical net benefit. The advantages and disadvantages of both models were evaluated using the integrated discrimination improvement and Net Reclassification Index. A calibration curve was constructed to assess predictive power and actual conditions. The external data sets were used to verify the predictive accuracy of the model. Results: All independent variables screened by Least Absolute Shrinkage and Selection Operator regression were independent risk factors for death in patients with severe heatstroke, which included neutrophil/lymphocyte ratio, platelet (PLT), troponin I, creatine kinase myocardial band, lactate dehydrogenase, human serum albumin, D-dimer, and APACHE-II scores. On days 10 and 30, the integrated discrimination improvement of the prediction model established was 0.311 and 0.364 times higher than that of the APACHE-II score, respectively; and the continuous Net Reclassification Index was 0.568 and 0.482 times higher than that of APACHE-II, respectively. Furthermore, we established that the area under the curve (AUC) of the prediction model was 0.905 and 0.918 on days 10 and 30, respectively. Decision curve analysis revealed that the AUC of this model was 7.67% and 10.67% on days 10 and 30, respectively. The calibration curve showed that the predicted conditions suitably fit the actual requirements. External data verification showed that the AUC on day 10 indicated by the prediction model was 0.908 (95% confidence interval, 82.2-99.4), and the AUC on day 30 was 0.930 (95% confidence interval, 0.860-0.999). Conclusion: The survival rate of patients with severe heatstroke within 24 h of admission on days 10 and 30 can be effectively predicted using a simple nomogram; additionally, this nomogram can be used to evaluate risks and make appropriate decisions in clinical settings.

O026 Post-operative mortality following planned versus on-demand relaparotomy for secondary bacterial peritonitis: a literature review

Abstract Introduction Post-operative peritonitis is a life-threatening complication of surgical care, whereby early relaparotomy is paramount in diagnosing and controlling the infective source. Currently, there are no clear guidelines on surgical strategies for re-laparotomy. This study aimed to evaluate the current evidence on the mortality rates and length of hospital admission associated with planned (PR) versus on-demand re-laparotomy (ODR) in patients with secondary peritonitis. Methods Literature review was conducted using Ovid MEDLINE and PubMed to identify English-language papers directly comparing ODR and PR in adults over 18 years. Case reports, reviews and papers including individuals with peritonitis post-pancreatitis or abdominothoracic surgery were excluded. Eight of the 154 studies identified met inclusion criteria following abstract screening. Results No significant difference was found between post-operative mortality in PR and ODR for patients with secondary peritonitis (mean mortality rates 30.0% and 31.7% respectively). ODR was shown to have better overall outcomes in avoiding unnecessary surgeries, reducing infection-related complications and length of ITU admissions. ODR is favoured provided there is no operation delay. However, in patients with extensive peritonitis and high APACHE-II scores, PR is preferred to effectively control infection source. Conclusion Literature analysis shows there is still much debate regarding whether PR or ODR is favoured for post-operative peritonitis. Further randomised control-trials across multiple international centres are required to improve the evidence base for future surgical practice. Take-home message Mortality and complication rates are comparable following planned and on-demand re-laparotomy in patients with post-operative peritonitis. Further international research is required to construct evidence-based guidelines for re-laparotomy and improve our future care for critically unwell surgical patients.

An analysis of the treatment effect of two modes of oxygenation on patients with radiation pneumonia complicated by respiratory failure.

Stereotactic radiotherapy (SBRT) is widely used in the treatment of thoracic cancer. To evaluate the efficacy of a non-rebreather mask (NRBM) and high-flow nasal cannula (HFNC) in patients with radiation pneumonia complicated with respiratory failure. This was a single-center randomized controlled study. Patients admitted to the EICU of the Fourth Hospital of Hebei Medical University were selected and divided into NRBM and HFNC group. Arterial blood gas analysis, tidal volume, respiratory rates and the cases of patients receiving invasive assisted ventilation were collected at 0, 4, 8, 12, 24, 48, and 72 h after admission. (1) The PaO2/FiO2, respiratory rates, and tidal volume between the two groups at 0, 4, 8, 12, 24, 48, and 72 h were different, with F values of 258.177, 294.121, and 134.372, all P< 0.01. These indicators were different under two modes of oxygenation, with F values of 40.671, 168.742, and 55.353, all P< 0.01, also varied with time, with an F value of 7.480, 9.115, and 12.165, all P< 0.01. (2) The incidence of trachea intubation within 72 h between HFNC and NRBM groups (23 [37.1%] vs. 34 [54.0%], P< 0.05). The transition time to mechanical ventilation in the HFNC and NRBM groups (55.3 ± 3.2 h vs. 45.9 ± 3.6 h, P< 0.05). (3) The risk of intubation in patients with an APACHE-II score > 23 was 2.557 times than score ⩽ 23, and the risk of intubation in the NRBM group was 1.948 times more than the HFNC group (P< 0.05). Compared with the NRBM, HFNC can improve the oxygenation state of patients with radiation pneumonia complicated with respiratory failure in a short time, and reduce the incidence of trachea intubation within 72h.

Clinical Efficacy Protocol of Yinhuapinggan Granules: A Randomized, Double-Blind, Parallel, and Controlled Clinical Trial Program for the Intervention of Community-Acquired Drug-Resistant Bacterial Pneumonia as a Complementary Therapy.

Background: Community-acquired bacterial pneumonia (CABP) is an important health care concern in the worldwide, and is associated with significant morbidity, mortality, and health care expenditure. Streptococcus pneumoniae is the most frequent causative pathogen of CABP. Common treatment for hospitalized patients with CABP is empiric antibiotic therapy using β-lactams in combination with macrolides, respiratory fluoroquinolones, or tetracyclines. However, overuse of antibiotics has led to an increased incidence of drug-resistant S. pneumoniae, exacerbating the development of community-acquired drug-resistant bacterial pneumonia (CDBP) and providing a challenge for physicians to choose empirical antimicrobial therapy. Methods: Traditional Chinese medicine (TCM) is widely used as a complementary treatment for CDBP. Yinhuapinggan granules (YHPG) is widely used in the adjuvant treatment of CDBP. Experimental studies and small sample clinical trials have shown that YHPG can effectively reduce the symptoms of CDBP. However, there is a lack of high-quality clinical evidence for the role of YHPG as a complementary drug in the treatment of CDBP. Here, we designed a randomized, double-blind, placebo-controlled clinical trial to explore the efficacy and safety of YHPG. A total of 240 participants will be randomly assigned to the YHPG or placebo group in a 1:1 ratio. YHPG and placebo will be added to standard treatment for 10 days, followed by 56 days of follow-up. The primary outcome is the cure rate of pneumonia, and the secondary outcomes includes conversion rate of severe pneumonia, lower respiratory tract bacterial clearance, lactic acid (LC) clearance rate, temperature, C-reactive protein (CRP), criticality score (SMART-COP score), acute physiological and chronic health assessment system (APACHEII score) and clinical endpoint events. Adverse events will be monitored throughout the trial. Data will be analyzed according to a pre-defined statistical analysis plan. This research will disclose the efficacy of YHPG in acquired drug-resistant pneumonia. Clinical Trial Registration: https://clinicaltrials.gov, identifier ChiCTR2100047501

Role of the protein C system in aggravation of acute pancreatitis

The goal of the study was to identify risk factors for coagulation and fibrinolysis in aggravation of acute pancreatitis (AP) based on 11 markers and APACHE-II score. The subjects were 42 patients with AP (12 severe AP and 30 mild AP) and 20 healthy controls. Measurements of antithrombin III (AT-III), plasminogen (Plg), platelet counts, lipopolysaccaride (LPS), thrombomodulin (TM), protein C (PC), activated protein C (APC), APC/PC ratio, free-protein S (f-PS), thrombin-antithrombin complex (TAT), and tissue-type plasminogen activator·PAI-1 (t-pA·PAI-1) complex and clinical scores were performed using ELISA kits and clinical examinations of patients. Fluctuations of most markers in the course of AP indicated abnormal activation from onset to 3 days. After 7 days, non-survivor severe AP (SAP) cases showed abnormal marker reactivation, while survivor SAP and mild AP (MAP) cases had gradual normalization of markers. At 7 days after onset and during all stages of progression of AP, there were significant differences between non-survivor SAP and survivor SAP cases for 5 and 8 markers, respectively, but APC and t-pA·PAI-1 complex were common to both. The TAT/APC and t-pA·PAI-1/APC ratios, which reflect APC generation, were higher in survivor SAP than in non-survivor SAP cases. A decrease in APC generation leading to excessive thrombin synthesis may be a risk factor for coagulation and fibrinolysis in aggravation of AP.

High blood Fas concentrations in non-survivor patients with traumatic brain injury.

Fas is one of the main death receptors of the extrinsic pathway of apoptosis. A study has reported higher Fas expression in brain samples of non-surviving TBI patients than in survivors. The objective of our current study was to determine whether there is an association between Fas concentrations in blood and mortality of isolated TBI patients. Patients with severe TBI [< 9 points in Glasgow Coma Scale (GCS)] and isolated TBI (< 10 non-cranial aspects points on the Injury Severity Score) were included from 5 Intensive Care Units. We measured serum Fas concentrations on the day of TBI. Non-surviving (n = 23) compared to surviving patients (n = 57) had higher age (p = 0.01), lower GCS (p = 0.001), higher APACHE-II score (p < 0.001), higher ICP (p = 0.01), higher CT findings with high risk of death (p = 0.02) and higher serum Fas concentrations (p < 0.001). We found in regression analyses an association between serum Fas levels and mortality of TBI patients after controlling for CT findings, age and CGS (OR = 1.006; 95% CI 1.001-1.011; p = 0.02), and after controlling for CT findings, ICP and APACHE-II (OR = 1.007; 95% CI 1.001-1.012; p = 0.02). Thus, the most interesting and novel finding in this study is the association between high blood Fas concentrations and mortality in TBI patients.

Comparative Analysis of Early Clinical Features and Complications of Different Types of Acute Pancreatitis.

Background Acute pancreatitis (AP) is a common surgical acute abdomen. Different kinds of pancreatitis may have different pathophysiological characteristics each other. The objective of this research was to investigate the early clinical features and complications of different types of acute pancreatitis. Methods 787 AP patients admitted in the Huadu District People's Hospital of Guangzhou during January 2009 and December 2019 were analyzed retrospectively. Among 787 AP patients, 520 (66.1%) were biliary AP (group I), 69 (8.7%) were alcoholic AP (group II), and 198 (25.2%) were hypertriglyceridemic AP (group III). According to the local and systemic complications and mortality in the early stage, we compared and analyzed the clinical characteristics and prognosis of different types of pancreatitis. Results Mild acute pancreatitis accounted for the highest proportion (79.4%) in group I, while moderately severe acute pancreatitis in group II (36.2%) and severe acute pancreatitis in group III (62.6%). In terms of severity score of the pancreatitis, the average scores of BISAP, Ranson, APACHE-II, and MCTSI of the patients in group III were the highest (p < 0.01). The incidence of acute peripancreatic fluid collection and infectious pancreatic necrosis was the highest in group III. The incidences of acute necrotic collection, pancreatic pseudocyst, and walled-off necrosis in group III were significantly higher than those in the other two groups (p < 0.01). The incidences of systemic inflammatory response syndrome, sepsis, multiple organ failure, intra-abdominal hypertension, and mortality were highest in group III. Conclusions There is an upward trend of the incidence rate of hypertriglyceridemic AP in recent years; it has been gradually developed into the second type of acute pancreatitis which is second only to the acute biliary pancreatitis. It is worthy to pay more and more attentions to it due to the feature of its younger onset, high incidence of complications, and high mortality.

APACHE scoring system and pressure injury risk for intensive care patients: A systematic review and meta-analysis.

The present study was designed to determine the association between Acute Physiology and Chronic Health Evaluation (APACHE) scale and elevated pressure injure (PI) risk in intensive care units (ICU) and also evaluate the predictive value of APACHE score in PI patients. Comprehensive strategies were used to search studies from PubMed, Web of Science, and Ovid Embase electronic databases for observational studies that provided data about APACHE scores related to PI in ICU. Eligible studies were selected based on inclusion and exclusion criteria. The pooled SMD with 95% confidence intervals were calculated. A summary ROC curve was plotted to calculate area under curve (AUC) for APACHE-II (15-20). Twenty-one studies involving 11,102 patients who met selection criteria were included. The 11.0% of patients (1229/11102) in ICU developed PIs. Overall, the PI group had a higher score compared with the non-PI group in the APACHE II (22.1 ± 8.0 vs. 14.5 ± 7.4, mean ± SD). The APACHE-III of PI patients was significantly more than that in the non-PI group (79.9 ± 25.6 vs. 59.9 ± 30.4, mean ± SD). The pooled SMD was 0.82 (95% CI: 0.58-1.06, I2 =91.7%, p-value < 0.001). The subgroup analysis revealed that the risk of PIs did not vary with the type of APACHE score (II, III, IV) and the type of study design (case-control, cross-sectional, cohort, longitudinal study). Proportion of males (I2 = 91.68%, p value=0.090), publish year (I2 = 91.96%, p value=0.187) and mean age of patients (I2 = 91.96%, p value=0.937) were not the sources of heterogeneity. APACHE-II (15-20) achieves the best predictive performance in PI, and the prediction accuracy was balanced with equal sensitivity and specificity (Sen: 0.72, 0.62-0.80; Spec: 1.72, 1.25-2.38). In conclusion, higher APACHE scores are frequently accompanied by a higher incidence of PI among critical-care patients. APACHE-II scores (15-20) satisfactorily predicted PI, and strategies to prevent PI should be aggressively implemented.

Inflammatory Markers as Early Predictors of Disease Severity in COVID-19 Patients Admitted to Intensive Care Units: A Retrospective Observational Analysis

BackgroundIn pandemic situations, it is essential that the limited resources are used judiciously to achieve most benefits. Prediction of the disease severity at the earliest will help in better allocation, thus, positively affecting prognosis and treatment.Aim and objectiveTo investigate patient characteristics and specific biomarkers as possible early predictors of disease severity of SARS-COV-2 infection.Materials and methodsRetrospective single-centric observational study conducted at 70-bedded intensive care unit of tertiary care hospital at Haryana, India. 100 consecutive RT-PCR positive coronavirus disease-2019 (COVID-19) adult patients. Demographics, acute physiology and chronic health evaluation II (Apache-II) score, and Inflammatory markers were compared with respect to oxygenation defect (PaO2/FiO2 ratio: <300 or ≥300 mm Hg), need of invasive ventilation, ICU length of stay and 28-day mortality.FindingsMean age was significantly more in lower PF ratio group (58.01 ± 15.33 vs 50.97 ± 13.78, p = 0.023) whereas sex ratio was comparable among patients in two groups. Significantly, higher APACHE-II score (p ≤0.001) and presence of hypertension (43.54% vs 23.68%; p = 0·045) in low PF ratio group along with higher C-reactive protein (171.78 ± 124.45 vs 101.52 ± 88.70), IL-6 (173.51 vs 53.18) and ferritin (1677.60 ± 2271.13 vs 643.54 ± 718.68) levels. Procalcitonin, lactate dehydrogenase, and creatine phosphokinase (CPK) levels were not significant.InterpretationAge and APACHE II score and among laboratory parameters CRP, ferritin, and IL-6 levels were significantly higher in low PF ratio group, patients requiring invasive ventilation and in mortality group. Use of this triad (CRP, ferritin, and IL-6 levels) at admission may predict the disease severity early in the course. Addition of APACHE-II may further improve the accuracy of the score.How to cite this articleGupta D, Jain A, Chauhan M, Dewan S. Inflammatory Markers as Early Predictors of Disease Severity in COVID-19 Patients Admitted to Intensive Care Units: A Retrospective Observational Analysis. Indian J Crit Care Med 2022;26(4):482–486.

MO303: Impact of Dexamethasone and Inhaled Nitric Oxide on Severe Acute Kidney Injury in Critically ill Patients With COVID-19

BACKGROUND AND AIMSKidney failure is the second most frequent condition after acute respiratory distress syndrome (ARDS) in critically ill patients with severe COVID-19 and is strongly associated with mortality. The aim of this multicentric study was to assess the impact of the specific treatments of COVID-19 and ARDS on the risk of severe acute kidney injury (AKI) in critically ill COVID patients.METHODData from a prospectively collected database of consecutive patients hospitalized in six ICUs for COVID-19 was retrospectively analysed. The incidence and severity of AKI were monitored during the entire ICU stay. Patients older than 18 years hospitalized in for COVID-19-related ARDS requiring mechanical ventilation were included.RESULTSA total of 164 patients were included in the final analysis, 97 (59.1%) displayed AKI, of which 39 had severe stage 3 AKI and 21 (12.8%) requiring renal replacement therapy (RRT). In univariate analysis, severe AKI was associated with ACEI exposure (P = .016), high blood pressure (P = .029), APACHE-II score (P = .004) and mortality at D28 (P = .008), D60 (P < .001) and D90 (P < .001). In multivariate analysis, the factors associated with the onset of stage 3 AKI were: exposure to CEI [OR: 4.238 (1.307–13.736); P = .016], APACHE II score (without age) [OR: 1.138 (1.044–1.241); P = .003] and iNO [OR: 5.694 (1.953–16.606); P = .001], protective factors were prone positioning [OR: 0.234 (0.057–0.967); P = .045] and dexamethasone [OR: 0.194 (0.053–0.713); P = .014].CONCLUSIONDexamethasone seems to prevent the risk of severe AKI and RRT, and iNO seems associated with severe AKI and RRT in critically ill patients with COVID-19. iNO must be used with caution in COVID-19 related ARDS.

The effects of continuous renal replacement therapy with different anticoagulation methods on the expression of cytokines in severe acute pancreatitis

ObjectiveSevere acute pancreatitis (SAP) is a highly morbid condition in general population as well as in solid organ transplant (SOT) recipients. The present study aimed to investigate the effect of continuous renal replacement therapy (CRRT) with different anticoagulation methods on the expression levels of cytokines in SAP. MethodsA total of 120 patients with SAP, admitted into our hospital between September 2017 and July 2020, were enrolled as the research subjects and randomly divided into a control group (60 cases) and a study group (60 cases). CRRT with low molecular weight (LMW) heparin‑calcium anticoagulation was conducted on patients in the control group, and CRRT with topical citrate + low-dose LMW heparin‑calcium anticoagulation was conducted on patients in the study group. The expressions of cytokines in the two groups were compared after treatment. ResultsThere was no significant difference in white blood cells (WBC), C-reactive proteins (CRP), and procalcitonin (PCT) before treatment between the two groups (P > 0.05). After treatment, the levels of WBC (P = 0.006), CRP (P < 0.001), and PCT (P < 0.001) were significantly lower in the study group when compared with those in the control group. There was no significant difference in the concentrations of interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-α (TNF-α) between the two groups before treatment (P > 0.05). After treatment, the concentrations of IL-6, IL-8, and TNF-α were significantly lower in the study group when compared with those in the control group. The APACHEII, SOFA and Ranson scores of the two groups were analyzed, and there was no difference between the two groups before treatment (P > 0.05). After treatment, the score of the study group was lower than that of the control group (P < 0.05). ConclusionCRRT with topical citrate + low-dose LMW heparin‑calcium anticoagulation in the treatment of patients with SAP reduces the levels of WBC, CRP, and PCT and the concentrations of cytokines, including IL-6, IL-8, and TNF-α. This inhibits the release of inflammatory mediators in patients with SAP and reduces damage to the body caused by the inflammatory response, thus effectively improving the patients' condition.

Compassionate use of Pulmonary Vasodilators in Acute Severe Hypoxic Respiratory Failure due to COVID-19.

BackgroundThere have been over 200 million cases and 4.4 million deaths from COVID-19 worldwide. Despite the lack of robust evidence one potential treatment for COVID-19 associated severe hypoxaemia is inhaled pulmonary vasodilator (IPVD) therapy, using either nitric oxide (iNO) or prostaglandins. We describe the implementation of, and outcomes from, a protocol using IPVDs in a cohort of patients with severe COVID-19 associated respiratory failure receiving maximal conventional support.MethodsProspectively collected data from adult patients with SARS-CoV-2 admitted to the intensive care unit (ICU) at a large teaching hospital were analysed for the period 14th March 2020 - 11th February 2021. An IPVD was considered if the PaO2/FiO2 (PF) ratio was less than 13.3kPa despite maximal conventional therapy. Nitric oxide was commenced at 20ppm and titrated to response. If oxygenation improved Iloprost nebulisers were commenced and iNO weaned. The primary outcome was percentage changes in PF ratio and Alveolar-arterial (A-a) gradient.ResultsFifty-nine patients received IPVD therapy during the study period. The median PF ratio before IPVD therapy was commenced was 11.33kPa (9.93-12.91). Patients receiving an IPVD had a lower PF ratio (14.37 vs. 16.37kPa, p = 0.002) and higher APACHE-II score (17 vs. 13, p = 0.028) at ICU admission. At 72 hours after initiating an IPVD the median improvement in PF ratio was 33.9% (-4.3-84.1). At 72 hours changes in PF ratio (70.8 vs. −4.1%, p < 0.001) and reduction in A-a gradient (44.7 vs. 14.8%, p < 0.001) differed significantly between survivors (n = 33) and non-survivors (n = 26).ConclusionsThe response to IPVDs in patients with COVID-19 associated acute hypoxic respiratory failure differed significantly between survivors and non-survivors. Both iNO and prostaglandins may offer therapeutic options for patients with severe refractory hypoxaemia due to COVID-19. The use of inhaled prostaglandins, and iNO where feasible, should be studied in adequately powered prospective randomised trials.

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

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

Nomogram Models for Predicting Delirium of Patients in Emergency Intensive Care Unit: A Retrospective Cohort Study.

BackgroundIntensive care unit (ICU) delirium is one of the most common clinical syndromes that results in many adverse events that affect patients, families, and hospitals. To date, there has been no tool for effectively predicting the occurrence of delirium in emergency intensive care unit (EICU) patients.MethodsWe conducted a retrospective cohort study and constructed a prediction model for 319 patients in EICU, who met our inclusion criteria. We analyzed the relationship between patients’ clinical data within 24 hours of admission and delirium, applied univariate and multivariate logistic regression analyses to select the most relevant variables for construction of nomogram models, then applied bootstrapping for internal validation.ResultsA total of five variables, namely stomach and urinary tubes, as well as sedative, mechanical ventilation and APACHE-II scores, were selected for model construction. We generated a total of five sets of models (three sets of construction models and two sets of internal verification models), with similar predictive value. The optimal model was selected, and together with the 5 variables used to construct a nomogram. The AUC of the MFP model in all patients was 0.76 (0.70, 0.82), whereas that in non-elderly patients (<60 years old) for the full model was 0.83 (0.74, 0.91). In elderly patients (≥60 years old), the AUC of the MFP model was 0.82 (0.73, 0.91).ConclusionOverall, the five-marker-based prognostic tool, established herein, can effectively predict the occurrence of delirium in EICU patients.

A retrospective, observational study: early versus late favipiravir in COVID-19 pneumonia

Aim: Positive results have been reported regarding the early use of favipiravir,a RNA-dependent RNA polymerase inhibitor,in the COVID-19 pandemic. In our study, we aimed to understand the potential role of favipiravir in controlling COVID-19 pneumonia and sepsis by comparing the early use of favipiravir with the late using.&#x0D; Material and Method: Treatments are carried out in line with the guidelines constantly updated by the Ministry of Health in Turkey. Following the guide published on April 14,2020,we examined 18 patients who received favipiravir as the last treatment option in the late period and 17 patients who received favipiravir in the early period in two different groups.We recorded the demographic characteristics,comorbidities,APACHE-II scores,consecutive SOFA scores and mortality status of the patients in both groups.&#x0D; Results: The difference between groups in terms of gender and age was not statistically significant.The difference between groups in terms of APACHE-II score was statistically significant.(p=0.018)The late group also had higher APACHE-II scores.The difference between groups in terms of exitus was not statistically significant but lower in the group using favipiravir early.&#x0D; Conclusion: In studies with a limited number of patients, favipiravir has been shown to have a significant advantage over lopinavir/ritonavir in viral clearance as well as a significant reduction in viral load when used in the early period.Similarly,in our study,patients who used favipiravir in the late period came to us more seriously and the mortality rate was higher. We think that favipiravir had a significant effect even in studies with a small number of patients, and larger studies are needed in this area.

Correlations between First 72 h Hypophosphatemia, Energy Deficit, Length of Ventilation, and Mortality-A Retrospective Cohort Study.

Introduction. Hypophosphatemia may prolong ventilation and induce weaning failure. Some studies have associated hypophosphatemia with increased mortality. Starting or restarting nutrition in a critically ill patient may be associated with refeeding syndrome and hypophosphatemia. The correlation between nutrition, mechanical ventilation, and hypophosphatemia has not yet been fully elucidated. Methods. A retrospective cohort study of 825 admissions during two consecutive years was conducted. Using the electronic medical chart, demographic and clinical data were obtained. Hypophosphatemia was defined as a phosphate level below 2.5 mg/dL (0.81 mmol/L) in the first 72 h of ICU admission. Comparisons between baseline characteristics and outcomes and multivariate analysis were performed. Results. A total of 324 (39.27%) patients had hypophosphatemia during the first 72 h of ICU admission. Patients with hypophosphatemia tended to be younger, with lower APACHE-II, SOFA24, and ΔSOFA scores. They had a longer length of stay and length of ventilation, more prevalent prolonged ventilation, and decreased mortality. Their energy deficit was lower. There was no effect of hypophosphatemia severity on these results. In multivariate analysis, hypophosphatemia was not found to be statistically significant either with respect to mortality or survivor’s length of ventilation, but lower average daily energy deficit and SOFA24 were found to be statistically significant with respect to survivor’s length of ventilation. Conclusion. Hypophosphatemia had no effect on mortality or length of ventilation. Lower average daily energy deficit is associated with a longer survivor’s length of ventilation.

Construction of a Nomogram Model for Predicting Pleural Effusion Secondary to Severe Acute Pancreatitis

Background This study aims to investigate the risk factors of pleural effusion (PE) secondary to severe acute pancreatitis (SAP) and to build a nomogram model. Methods The clinical parameters of SAP patients admitted to the emergency department of the First Affiliated Hospital of Bengbu Medical College from January 2019 to August 2021 were retrospectively collected. The independence risk factors of PE secondary to SAP were analyzed by univariate analysis and multivariate logistic regression analysis. A nomogram risk prediction model was established and validated through the area under the ROC curve. Result Two hundred twenty-two SAP patients were included for analysis, of which 65 patients experienced secondary PE. The incidence of PE secondary to SAP was 29.28% (65/222). Logistic regression analysis showed that serum albumin (ALB) (OR = 0.830, 95% CI: 0.736∼0.936), fibrinogen (FIB) (OR = 4.573, 95% CI: 1.795∼11.648), C-reactive protein (CRP) (OR = 1.046, 95% CI: 1.009∼1.083), acute physiology, chronic health score system (APACHE-II) score (OR = 1.484, 95% CI: 1.106∼1.990), and sequential organ failure score (SOFA) (OR = 43.038, 95% CI: 2.030∼4.548) were independent risk factors for PE secondary to SAP (P < 0.05) and entered into the nomogram. The nomogram showed robust discrimination with an index of concordance of 0.755 and an area under the receiver operating characteristic curve of 0.837 (95% CI: 0.779∼0.894). Conclusion We developed a nomogram model for PE secondary to SAP with ALB, FIB, CRP, APACHE-II scores, and SOFA scores. The nomogram model showed good discrimination and consistency, and it can better predict the risk of PE secondary to SAP.

Prognostic Value of Mid-Regional Proadrenomedullin Sampled at Presentation and after 72 Hours in Septic Patients Presenting to the Emergency Department: An Observational Two-Center Study.

The prognostic value of mid-regional proADM (MR-proADM) in septic patients presenting to the emergency department (ED) is not well established. In this prospective observational study enrolling septic patients evaluated in two EDs, MR-proADM was measured at arrival (t0) and after 72 h (t72). MR-proADM%change was calculated as follows: (MR-proADMt72h − MR-proADMt0)/MR-proADMt0. In total, 147 patients were included in the study, including 109 with a final diagnosis of sepsis and 38 with septic shock, according to the Sepsis-3 criteria. The overall 28-day mortality (outcome) rate was 12.9%. The AUC for outcome prognostication was 0.66 (95% CI 0.51–0.80) for MR-proADMt0, 0.77 (95% CI 0.63–0.92) for MR-proADMt72 and 0.74 (95% CI 0.64–0.84) for MR-proADM%change. MR-proADMt0 ≥ 2.78 nmol/L, MR-proADMt72 ≥ 2.7 nmol/L and MR-proADM%change ≥ −15.2% showed statistically significant log-rank test results and sensitivity/specificity of 81/65%, 69/80% and 75/70% respectively. In regression analysis, MR-proADM%change was a significant outcome predictor both in univariate and multivariate analysis, after adjustment for age, SOFA and APACHEII scores, providing up to 80% of added prognostic value. In conclusion, time trends of MR-proADM may provide additional insights for patient risk stratification over single sampling. MR-proADM levels sampled both at presentation and after 72 h predicted 28-day survival in septic patients presenting to the ED.

Analysis of the Occurrence of Acute Pulmonary Embolism in the ICU Ward and Related Risk Factors Predicting Its Severity.

To investigate the occurrence of acute pulmonary embolism in the intensive care unit (ICU) and analyze the related risk factors for predicting its severity. From January 2016 to December 2020, 83 patients with acute pulmonary embolism in the intensive care unit of Peking University People's Hospital were selected as the research subjects, including 34 males (40.96%) and 49 females (59.04%), with an average age of 62.06±16.83 years. The patients were divided into a high-risk group (N = 31), medium-risk group (N = 32), and low-risk group (N = 20), according to the guidelines for diagnosis and treatment of acute pulmonary embolism issued by ASH in 2020. The clinical characteristics, treatment, and prognosis of the three groups were summarized, and the severity of the patients could be predicted and the related risk factors affecting prognosis were analyzed. There were significant statistical differences in respiratory rate, syncope as the first symptom, bilateral pulmonary embolism, and APACHE-II score among the three groups (P < 0.05). There were significant statistical differences in the laboratory indexes, such as BNP, cTnI and D-dimer before and immediately after APE among the three groups (P < 0.05). There were significant statistical differences in cTnI and D-dimer among the three groups (P < 0.05). By pairwise comparison, it was found that there were significant statistical differences between the high-risk and low-risk groups in the immediate test indexes of APE, such as BNP, D-dimer, lower extremity vascular ultrasound abnormalities, and ECG abnormalities (P < 0.05), while there was no significant statistical difference between the medium-risk and low-risk groups in the immediate test indexes of APE (P > 0.05). However, in the medium-risk group, the laboratory indexes tended to increase, in terms of treatment and outcome, thrombolysis rate, and inferior vena cava filter implantation rate. ICU stay (> 2 weeks) of the high-risk group was significantly higher than those of the other two groups, with significant statistical difference (P < 0.05). Logistic regression analysis showed that respiratory rate (or = 1.778,95% CI 1.043-3.032, P = 0.034), D-Dimer (or = 1,95% CI 1.0-1.0, P = 0.006), and APACHE-II score (or = 1.879,95% CI 1.398-2.527, P = 0.000) were independent risk factors for predicting the severity of APE patients in the ICU ward. Acute pulmonary embolism (APE) is a critical disease in ICU. By monitoring BNP, cTnI and D-dimer, we can identify critical patients with APE early. In addition, we found that respiratory rate, D-dimer, and APACHE-II score were independent risk factors for predicting the severity of APE patients in the ICU. Clinically, APE can be identified early. The diagnosis, treatment rate, and prognosis can be improved by monitoring these indicators.

TO PROGNOSTICATE THE OUTCOME IN PATIENT WITH PERFORATION PERITONITIS BY EVALUATING MANNHEIM PERITONITIS INDEX &amp; APACHE-II SCORING SYSTEM

Introduction: Peritonitis presents most commonly due to the localized or generalized infection. Studies have reported APACHE II to be a better system for prognostication of the outcome of patients with peritonitis, while others concluded that MPI provides a more reliable means of risk evaluation. The present study is conducted with the objective to nd out efcacy of MPI in comparison to APACHE II to prognosticate the outcome in patients with perforation peritonitis. Material and methods: This was a prospective hospital based analytical study conducted in department of surgery at Dr. BRAM Hospital, Raipur of Pt. JNMCH Raipur. Total 100 patients with peritonitis fullls the inclusion criteria was included in the study. Both scoring system is applied for the individual patient at admission or within 24 hours. Data was analysed using SPSS version 20.0. Descriptive statistics; frequency, percentage statistical signicance and p value were calculated. Results: The mean age of study subjects was 43.89±15.75 years. Of that (84%) were males. The chief complaint was abdominal pain and not passing atus. The primary outcome shows that one third was died during treatment and rests were discharged. The mean APACHE-II and MPI score among death cases was 14.7 and 25.2. APACHE-II score has sensitivity of 83% and specicity of 94% whereas MPI score has sensitivity of 51% and specicity of 77%. Conclusion: Though MPI did not prove to be as good as APACHE II in this study, there is denitely benet in using the MPI scores in primary and secondary level hospitals where facilities are less and investigations such as blood gas may not be available. They can be used to ascertain a certain extent of the patient's present condition and the prognosis