Common Cause Of Critical Illness Research Articles

Focus on host/organ unregulated response: a common cause of critical illness.

Focus on host/organ unregulated response: a common cause of critical illness.

Dead space fraction for treatment guidance and prognosis evaluation of acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is a common cause of critical illness and high mortality from respiratory failure. Increased dead space fraction (VD/VT) was independently associated with lung injury and mortality of ARDS. VD/VT is readily obtained by bedside measurements of arterial blood gas and end-tidal carbon dioxide. Early attention and application of VD/VT as an indicator will help to better understand the pathophysiological of ARDS, guide clinical treatment, and better assess the severity and clinical prognosis of the disease.

Lipidomic signatures align with inflammatory patterns and outcomes in critical illness

Alterations in lipid metabolism have the potential to be markers as well as drivers of pathobiology of acute critical illness. Here, we took advantage of the temporal precision offered by trauma as a common cause of critical illness to identify the dynamic patterns in the circulating lipidome in critically ill humans. The major findings include an early loss of all classes of circulating lipids followed by a delayed and selective lipogenesis in patients destined to remain critically ill. The previously reported survival benefit of early thawed plasma administration was associated with preserved lipid levels that related to favorable changes in coagulation and inflammation biomarkers in causal modelling. Phosphatidylethanolamines (PE) were elevated in patients with persistent critical illness and PE levels were prognostic for worse outcomes not only in trauma but also severe COVID-19 patients. Here we show selective rise in systemic PE as a common prognostic feature of critical illness.

Altered Metabolic Profile of Triglyceride-Rich Lipoproteins in Gut-Lymph of Rodent Models of Sepsis and Gut Ischemia-Reperfusion Injury.

Triglyceride-rich lipoproteins are important in dietary lipid absorption and subsequent energy distribution in the body. Their importance in the gut-lymph may have been overlooked in sepsis, the most common cause of critical illness, and in gut ischemia-reperfusion injury, a common feature of many critical illnesses. We aimed to undertake an exploratory study of triglyceride-rich lipoprotein fractions in gut-lymph using untargeted metabolic profiling to identify altered metabolites in sepsis or gut ischemia-reperfusion. The gut-lymph was collected from rodent sham, sepsis, and gut ischemia-reperfusion models. The triglyceride-rich lipoprotein-enriched fractions isolated from the gut-lymph were subjected to a dual metabolomics analysis approach: non-polar metabolite analysis by ultra-high performance liquid chromatography-mass spectrometry and polar metabolite analysis by gas chromatography-mass spectrometry. The metabolite analysis of gut-lymph triglyceride-rich lipoprotein fractions revealed a significant increase (FDR-adjusted P value < 0.05) in myo-inositol in the sepsis group and monoacylglycerols [(18:1) and (18:2)] in gut ischemia-reperfusion. There were no significantly increased specific metabolites in the lipoprotein-enriched fractions of both sepsis and gut ischemia-reperfusion. In contrast, there was a widespread decrease in multiple lipid species in sepsis (35 out of 190; adjusted P < 0.05), but not in the gut ischemia-reperfusion. Increased levels of myo-inositol and monoacylglycerols, and decreased multiple lipid species in the gut-lymph triglyceride-rich lipoprotein fraction could be candidates for new biomarkers and/or involved in the progression of sepsis and gut ischemia-reperfusion pathobiology.

Acute spontaneous intracerebral hemorrhage and traumatic brain injury are the most common causes of critical illness in the ICU and have high early mortality

BackgroundCritical care covers multiple disciplines. However, the causes of critical illness in the ICU, particularly the most common causes, remain unclear. We aimed to investigate the incidence and the most common causes of critical illness and the corresponding early mortality rates in ICU patients.MethodsA retrospective cohort study was performed to examine critically ill patients (aged over 15 years) in the general ICU in Shuyang County in northern China (1/2014–12/2015). The incidences and causes of critical illnesses and their corresponding early mortality rates in the ICU were determined by an expert panel.ResultsDuring the 2-year study period, 1,211,138 person-years (PY) and 1645 critically ill patients (mean age, 61.8 years) were documented. The median Glasgow Coma Scale (GCS) score was 6 (range, 3–15). The mean acute physiology and chronic health evaluation II (APACHE II) score was 21.2 ± 6.8. The median length of the ICU stay was 4 days (range, 1–29 days). The most common causes of critical illness in the ICU were spontaneous intracerebral hemorrhage (SICH) (26%, 17.6/100,000 PY) and traumatic brain injury (TBI) (16.8%, 11.4/100,000 PY). During the first 7 days in the ICU, SICH was the most common cause of death (42.2%, 7.4/10,000 PY), followed by TBI (36.6%, 4.2/100,000 PY). Based on a logistic analysis, older patients had a significantly higher risk of death from TBI (risk ratio [RR], 1.7; 95% CI, 1.034–2.635), heart failure/cardiovascular crisis (RR, 0.2; 95% CI, 0.083–0.484), cerebral infarction (RR, 0.15; 95% CI, 0.050–0.486), or respiratory failure (RR, 0.35; 95% CI, 0.185–0.784) than younger patients. However, the risk of death from SICH in the two groups was similar.ConclusionsThe most common causes of critical illness in the ICU were SICH and TBI, and both critical illnesses showed a higher risk of death during the first 7 days in the ICU.

Tropical diseases in the ICU: A syndromic approach to diagnosis and treatment

Tropical infections form 20–30% of ICU admissions in tropical countries. Diarrheal diseases, malaria, dengue, typhoid, rickettsial diseases and leptospirosis are common causes of critical illness. Overlapping clinical features makes initial diagnosis challenging. A systematic approach involving (1) history of specific continent or country of travel, (2) exposure to specific environments (forests or farms, water sports, consumption of exotic foods), (3) incubation period, and (4) pattern of organ involvement and subtle differences in manifestations help in differential diagnosis and choice of initial empiric therapy. Fever, rash, hypotension, thrombocytopenia and mild derangement of liver function tests is seen in a majority of patients. Organ failure may lead to shock, respiratory distress, renal failure, hepatitis, coma, seizures, cardiac arrhythmias or hemorrhage. Diagnosis in some conditions is made by peripheral blood smear examination, antigen detection or detection of microbial nucleic acid by PCR. Tests that detect specific IgM antibody become positive only in the second week of illness. Initial therapy is often empiric; a combination of intravenous artesunate, ceftriaxone and either doxycycline or azithromycin would cover a majority of the treatable syndromes. Additional antiviral or antiprotozoal medications are required for some specific syndromes. Involving a physician specializing in tropical or travel medicine is helpful.

536P Characteristics and outcome of cancer patients with sepsis requiring admission to the intensive care unit

Background Cancer patients have a nearly 10-fold risk of developing sepsis compared with patients without malignancy. Sepsis is the leading cause of ICU admission in cancer patients. Until the end of the previous century it remained controversial to admit cancer patients to the ICU for advanced-life-supporting therapy. However, over the past few years several center over the world have shown that it is possible to achieve a meaningful survival in these patients. The objective of this study is to assess the characteristics and outcomes in cancer patients admitted to the intensive care unit (ICU) for sepsis. Methods We performed a retrospective cohort study among cancer patients admitted to the ICU for sepsis in Moewardi Hospital between April 2015- April 2016. Every adult patient with a definite diagnosis of cancer and presenting with sepsis at ICU admission was evaluated. Medical history, physical and laboratory findings on admission, and therapeutic interventions during ICU stay were recorded. The main outcome was ICU mortality Results Of the 311 patients admitted to ICU for Sepsis, 40 (12,9%) patients had a definite diagnosis of cancer. Hematologic malignancy (mostly non hodgkin lymphoma and multiple myeloma) affected 35% (N = 14), and solid tumors(mostly cervical cancer and colorectal cancer) affected 65% (N = 26) patients. Mean age was 53 years (SD 14.3), 55% were female.The most frequent sites of infection were the lungs (35%), urinary tract (27.5%) and intra-abdominal region (22%).The median length of stay was 5 days. Eleven patients (27%) developed an Acute Kidney Injury (AKI) during their ICU stay. AKI occurred significantly more frequent in solid tumor patient as compared to hematologic malignancy patients (90,9% vs 9,1%, p < 0,05). Overall ICU mortality rate was 52.5%. There was no significant difference in ICU mortality rates between patients with hematologic malignancies and solid tumors (64.3% vs 46,2%, p = 0.273) Conclusions Sepsis is a common cause of critical illness in patients with cancer and associated with high mortality. Overall ICU mortality rate was 52.5%. We found that ICU mortality rates of patients with hematologic malignancies and solid tumors were similar Legal entity responsible for the study Department of Internal Medicine, Faculty of Medicine, Sebelas Maret University- Moewardi Hospital, Surakarta, Indonesia Funding Department of Internal Medicine, Faculty of Medicine, Sebelas Maret University- Moewardi Hospital, Surakarta, Indonesia Disclosure All authors have declared no conflicts of interest.

A national Infection in Critical Care Quality Improvement Programme for England: A survey of stakeholder priorities and preferences.

Severe infection is one of the most common causes of critical illness. Healthcare-associated infections complicating critical illness bring the additional challenge of multidrug resistance. However, England lacks a national surveillance system for infections in intensive care units. Prior experience with surveillance systems suggests that they are most effective when placed within a collaborative quality improvement framework. A national survey of adult, paediatric and neonatal intensive care doctors, nurses, microbiologists and infection control practitioners was undertaken throughout the UK to determine stakeholder engagement. Of 763 respondents (80% ICU physicians; 8% nurses) from 158 hospital Trusts across the UK, 721 (94.4%) supported establishing a surveillance system; 63.5% preferred that data collection be mandatory; 47.5% considered that the work should be undertaken within existing resources. Respondents prioritised catheter-associated and multidrug resistant infections. Free-text responses demonstrated strong support for using the data for epidemiological information and benchmarking for quality improvement. The survey provides a satisfactory foundation for establishing a national surveillance system for infection prevention and control in critical care in England.

Sepsis-Associated Outcomes in Critically Ill Patients with Malignancies.

Sepsis is a major cause of mortality among critically ill patients with cancer. Information about clinical outcomes and factors associated with increased risk of death in these patients is necessary to help physicians recognize those patients who are most likely to benefit from ICU therapy and identify possible targets for intervention. In this study, we evaluated cancer patients with sepsis chosen from a multicenter prospective study to characterize their clinical characteristics and to identify independent risk factors associated with hospital mortality. Subgroup analysis of a multicenter prospective cohort study conducted in 28 Brazilian intensive care units (ICUs) to evaluate adult cancer patients with severe sepsis and septic shock. We used logistic regression to identify variables associated with hospital mortality. Of the 717 patients admitted to the participating ICUs, 268 (37%) had severe sepsis (n = 142, 53%) or septic shock (n = 126, 47%). These patients comprised the population of the present study. The mean score on the third version of the Simplified Acute Physiology Score was 62.9 ± 17.7 points, and the median Sequential Organ Failure Assessment score was 9 (7-12) points. The most frequent sites of infection were the lungs (48%), intraabdominal region (25%), bloodstream as primary infection (19%), and urinary tract (17%). Half of the patients had microbiologically proven infections, and Gram-negative bacteria were the most common pathogens causing sepsis (31%). ICU and hospital mortality rates were 42% and 56%, respectively. In multivariable analysis, the number of acute organ dysfunctions (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.16-1.87), hematological malignancies (OR, 2.57; 95% CI, 1.05-6.27), performance status 2-4 (OR, 2.53; 95% CI, 1.44-4.43), and polymicrobial infections (OR, 3.74; 95% CI, 1.52-9.21) were associated with hospital mortality. Sepsis is a common cause of critical illness in patients with cancer and remains associated with high mortality. Variables related to underlying malignancy, sepsis severity, and characteristics of infection are associated with a grim prognosis.

Pulmonary Mechanics Following Albuterol Therapy in Mechanically Ventilated Infants with Bronchiolitis

Background and aims. Bronchiolitis is a common cause of critical illness in infants. Inhaled β2-agonist bronchodilators are frequently used as part of treatment, despite unproven effectiveness. The purpose of this study was to describe the physiologic response to these medications in infants intubated and mechanically ventilated for bronchiolitis. Materials and methods. We conducted a prospective trial of albuterol treatment in infants intubated and mechanically ventilated for bronchiolitis. Before and for 30 minutes following inhaled albuterol treatment, sequential assessments of pulmonary mechanics were determined using the interrupter technique on repeated consecutive breaths. Results: Fifty-four infants were enrolled. The median age was 44 days (25–75%; interquartile range (IQR) 29–74 days), mean hospital length of stay (LOS) was 18.3 ± 13.3 days, mean ICU LOS was 11.3 ± 6.4 days, and mean duration of mechanical ventilation was 8.5 ± 3.5 days. Fifty percent (n = 27) of the infants were male, 81% (n = 44) had public insurance, 80% (n = 41) were Caucasian, and 39% (n = 21) were Hispanic. Fourteen of the 54 (26%) had reduction in respiratory system resistance (Rrs) that was more than 30% below baseline, and were defined as responders to albuterol. Response to albuterol was not associated with demographic factors or hospitalization outcomes such as LOS or duration of mechanical ventilation. However, increased Rrs, prematurity, and non-Hispanic ethnicity were associated with increased LOS. Conclusions. In this population of mechanically ventilated infants with bronchiolitis, relatively few had a reduction in pulmonary resistance in response to inhaled albuterol therapy. This response was not associated with improvements in outcomes.

The epidemiology of Hajj-related critical illness

The annual Hajj experience has direct relevance for other jurisdictions planning rapid deployment strategies for intensive care for large groups during expected or emergent events. Approximately 2-3 million Muslims from over 160 countries travel to Saudi Arabia each year for Hajj. These pilgrims are typically older adults with a spectrum of comorbid conditions and of various ethnicities. This, coupled with a 2-wk period of physical migration in close contact with others, can lead to acute and critical illness from a variety of infectious and noninfectious causes and a requirement for full-scale but temporary intensive care to a large population. We describe patient characteristics, patterns of disease, and critical illness, including episodes of Influenza A 2009 (H1N1), therapies delivered, and clinical outcomes. Prospective cohort study of 110 critically ill patients in four hospitals during the 2009 ("1431": November 18 to December 4) Hajj in Saudi Arabia. Median (interquartile range) age was 60.5 (51.3-70) yrs, 69 (62.7%) were male, and Acute Physiology and Chronic Health Evaluation IV score was 60.5 (47-78.3). Forty-one patients (37.3%) were critically ill due to cardiovascular diseases (23.6% with myocardial infarction); 51 (46.4%) had severe infections (21.8% with H1N1); electrolyte disturbance (21.8%); or pulmonary illness (15.5%). Sixty patients (54.6%) required ventilation. Median predicted mortality by Acute Physiology and Chronic Health Evaluation IV was 14% while actual short-term mortality was 6.4% (p = .009). Longer-term mortality may be higher. Both event-specific conditions and patient-specific comorbid conditions are common causes of critical illness during large gatherings. With the ability to provide temporary but full-service intensive care, morbidity and mortality due to critical illness can be low, even among an older patient population and difficult care conditions.

Genetics of the Beta-Adrenergic Receptor and Response to Albuterol in Children With Bronchiolitis

PURPOSE: Bronchiolitis is a common cause of critical illness in children. Despite no clear evidence of their efficacy, inhaled bronchodilators, such as β2-adrenergic receptor (ADRβ2) agonists, are frequently used as part of treatment. Our hypothesis was that genotypic differences within the ADRβ2 are associated with response to ADRβ2 agonist treatment in children with bronchiolitis.

β2-Adrenergic Receptor Polymorphisms Affect Response to Treatment in Children With Severe Asthma Exacerbations

beta(2)-adrenergic receptor (AR) agonists are the mainstay of treatment for severe asthma exacerbations, one of the most common causes of critical illness in children. Genotypic differences in the beta(2)-AR gene, particularly at amino acid positions 16 and 27, have been shown to affect the response to beta(2)-AR agonist therapy. Our hypothesis is that genotypic differences contribute to patient response to beta(2)-AR agonist treatment during severe asthma exacerbations in children. Children admitted to the hospital ICU for a severe asthma exacerbation between 2002 and 2005 were located, and genetic samples were obtained from saliva. Children hospitalized during this period were treated with a protocol that titrated beta(2)-AR therapy (first nebulized, then IV) according to a validated clinical asthma score. Thirty-seven children hospitalized during the study period were enrolled into the study. At amino acid position 16 in the beta(2)-AR gene, 13 children were homozygous for the glycine (Gly) allele (Gly/Gly), 8 were homozygous for the arginine (Arg) allele (Arg/Arg), and 16 were heterozygous (Arg/Gly). Despite similar clinical asthma scores on hospital admission, the children with the Gly/Gly genotype had significantly shorter hospital ICU length of stay and duration of continuously nebulized albuterol therapy and were significantly less likely to require IV beta(2)-AR therapy than those with Arg/Arg or Arg/Gly genotypes. No association existed among polymorphisms at amino acid position 27 and response to beta(2)-AR therapy. In this cohort of children with severe asthma exacerbations, children whose genotypes were homozygous for Gly at amino acid position 16 of the beta(2)-AR gene had a more rapid response to beta(2)-AR agonist treatment. The beta(2)-AR genotype appears to influence the response to therapy in this population.

Beta2-Adrenergic Receptor Polymorphisms Influence Response To Treatment In African-American Children With Near Fatal Asthma

RATIONALE: Near fatal asthma exacerbations are a common cause of critical illness in children and β2-adrenergic receptor (β2-AR) agonists are the foundation of treatment for these exacerbations. Genotypic differences in the β2-AR, particularly at amino acid positions 16 and 27, have been linked to response to β2-AR agonist therapy. African-American children with asthma are a population particularly susceptible to near fatal exacerbations. Our hypothesis was that genotypic differences in the β2-AR are associated with treatment response in African-American children with near fatal asthma exacerbations.

Factors associated with asthma exacerbations during a long-term clinical trial of controller medications in children

Asthma exacerbations are a common cause of critical illness in children. To determine factors associated with exacerbations in children with persistent asthma. Regression modeling was used to identify historical, phenotypic, treatment, and time-dependent factors associated with the occurrence of exacerbations, defined by need for oral corticosteroids or emergency or hospital care in the 48-week Pediatric Asthma Controller Trial study. Children age 6 to 14 years with mild-to-moderate persistent asthma were randomized to receive either fluticasone propionate 100 microg twice daily (FP monotherapy), combination fluticasone 100 microg AM and salmeterol twice daily, or montelukast 5 mg once daily. Of the 285 participants randomized, 48% had 231 exacerbations. Using a multivariate analysis, which included numerous demographic, pulmonary, and inflammatory parameters, only a history of an asthma exacerbation requiring a systemic corticosteroid in the past year (odds ratio [OR], 2.10; P < .001) was associated with a subsequent exacerbation during the trial. During the trial, treatment with montelukast versus FP monotherapy (OR, 2.00; P = .005), season (spring, fall, or winter vs summer; P < or = .001), and average seasonal 5% reduction in AM peak expiratory flow (OR, 1.21; P = .01) were each associated with exacerbations. Changes in worsening of symptoms, beta-agonist use, and low peak expiratory flow track together before an exacerbation, but have poor positive predictive value of exacerbation. Children with mild-to-moderate persistent asthma with previous exacerbations are more likely to have a repeat exacerbation despite controller treatment. Inhaled corticosteroids are superior to montelukast at modifying the exacerbation risk. Available physiologic measures and biomarkers and diary card tracking are not reliable predictors of asthma exacerbations.