Day Of Intensive Care Unit Admission Research Articles

The characteristics and outcomes of oncology patients in intensive care unit in a tertiary care hospital in Saudi Arabia

Background: Many cancer patients need admission to intensive care unit (ICU). It is important to identify patients who will benefit most from ICU care. Objective: The current study aimed to identify the clinical features associated with outcomes and factors predicting ICU mortality of cancer patients at a tertiary care hospital in Riyadh, Saudi Arabia. Materials and Methods: This was a single-center, retrospective study of all adult patients with either hematological or solid cancer admitted to ICU between January 2017 and June 2018 at King Fahad Medical City, Riyadh, Saudi Arabia. Collected data included: patients' demographics, type of cancer, diagnosis, stage of disease, number of organs failure, reason for ICU admission, severity scores (Acute Physiology and Chronic Health Evaluation [APACHE] II, and Sepsis-related Organ Failure Assessment [SOFA] score), code status, interventions in the ICU, and outcomes. Results: A total of 108 cancer patients were admitted 128 times to ICU during the specified study period. Overall, mortality rate was 57% with standardized mortality rate according to the APACHE II of 0.75. Associative mortality included: vasopressor agents odds ratio (OR) = 3.44, cardiopulmonary resuscitation (CPR) before ICU admission OR = 3.35, presence of sepsis OR = 2.64, and need for invasive ventilatory support OR = 2.16. A total of 46 patients (43%) had hematological malignancies, whereas 62 (57%) had solid organ malignancies. Septic shock ranked first (44%) as the main reason for ICU admission. The mortality rate among hematological and solid organ cancer patients were 52% and 61%, respectively. The code status was do not resuscitate (DNR) in 55 patients (51%), 22% of the DNR patients were survivors. Twelve patients (22%) were DNR before ICU admission, whereas 43 (78%) were made DNR during their ICU stay. Most of ICU mortalities for both groups occurred within the first 20 days of ICU admission. Conclusion: Cancer patients admitted to ICU has high mortality rates; however, this does not preclude aggressive treatment for some. Factors associated with mortality include vasopressors, CPR, sepsis, and mechanical ventilation. Change of code status to DNR during ICU stay is common.

White Blood Cell Count Trajectory and Mortality in Septic Shock: A Retrospective Cohort Study

Background: Septic shock is among the most common causes of admission to medical intensive care units (ICU) and is associated with mortality of 20-40%. The white blood cell count (WBC) at time of admission correlates with prognosis in septic shock but it is not known if the change in WBC over time (i.e. the WBC trajectory) impacts survival.Hypothesis: We hypothesized that the trajectory of the WBC count in septic shock can identify distinct clinical groups and be an independent predictor of 30-day mortality.Objectives: 1) To identify groups of patients with different WBC trajectories using group-based trajectory analysis; 2) To evaluate patient and illness factors associated with WBC count trajectories; and 3) To estimate the association of WBC trajectory with mortality in septic shock.Methods: We completed a retrospective cohort study of adult patients with septic shock admitted to an ICU in Winnipeg, Canada between 2006-2014. We used group-based trajectory analysis to analyze the trend of WBC over the first 7 days of ICU admission to group patients according to stastically similar trajectories. Group-based trajectory analysis is a statistical method that can be used to describe the pattern of a variable over time. Rather than pre-specifying groups within a population, or using methods to measure an average trajectory for the entire population, group-based trajectory analysis allows for different groups with different trajectories to emerge. We used the Bayesian Information Criterion (BIC) and clinical validity characteristics to select the optimal trajectory model. We developed a multinomial logistic regression model to evaluate the association of patient and illness factors with WBC trajectories. We constructed a multivariable Cox proportional hazard models adjusted for age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, comorbidities, infection type and antibiotics to evaluate the association of WBC trajectory on 30-day mortality.Results: Our final study cohort comprised 917 patients with septic shock. The favoured model identified 7 distinct trajectories of WBC (Figure 1). We found that only baseline platelet count and sex were associated with WBC trajectory. The 30-day mortality of the entire cohort was 26.3%, and ranged from 23.1% in group 4 to 63% in group 5 (rising WBC trajectory). In a multivariable Cox proportional hazard model, group 5 was independently associated with an increased hazard of death (Hazard Ratio 3.48, 95% CI 1.92 to 6.35, p<0.01).Conclusions: We found seven unique and clinically relevant groups of patients with septic shock using trajectory analysis of the WBC count. Routine baseline characteristics are poor predictors of trajectory group assignment. The rising WBC trajectory is associated with an increased risk of death in septic shock. Further studies are required to fully describe the clinical characteristics and prognosis associated with distinct WBC trajectories and whether this information can inform level of care decisions and anticipated response to treatments. In the era of Big Data, trajectory analysis will be broadly applicable to the field of hematology where trends in blood counts or biomarkers of disease may provide valuable clinical or prognostic information. Examples could include analysis of the M-protein trajectory in Multiple Myeloma, and the trajectory of platelet counts in immune thrombocytopenia. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Serum procalcitonin levels predict acute kidney injury in critically ill patients.

To determine whether admission procalcitonin (PCT) was associated with the subsequent development of acute kidney injury (AKI) in a general population of critically ill patients. The study was a retrospective observational study conducted in a multidisciplinary intensive care unit (ICU) over a period of 1 year. Adult patients who had a PCT performed on admission and who did not have chronic kidney disease (CKD) or AKI on admission, were evaluated for the development of AKI within the first week of ICU admission, according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. The association between PCT on admission and the development of AKI was explored for the entire cohort and for septic and non-septic subgroups. Two hundred and one patients were included in the study. The incidence of AKI in the first 7 days of ICU admission was 36.8%. PCT, age, the presence of shock on admission, and sepsis were significantly associated with AKI on univariate analysis. Multivariable analysis of the entire cohort revealed that age, shock and sepsis remained independent predictors of AKI, while PCT was no longer significant. When the septic and non-septic patients were analyzed separately a PCT ≥10 ng/mL remained the only significant predictor of AKI in the non-septic patients (OR 4.430; 95% CI 1.464-13.399), but was not an independent predictor of AKI in septic patients. The main finding of this study was the significant association of an elevated PCT on admission with the development of AKI in the non-septic patient. An elevated PCT in a non-septic patient identifies a patient at increased risk of AKI. PCT requires further study as a novel biomarker of AKI in non-septic patients.

1478. A Retrospective Review of Pseudomonas aeruginosa Infection in a Quarternary Intensive Care Unit: Epidemiology, Outcomes, and Antimicrobial Susceptibilities: 2013–2016

BackgroundPseudomonas aeruginosa (PA) is known to cause infection in the intensive care unit (ICU) and contribute to substantial morbidity and mortality. The objectives of this study were to describe the epidemiology, antimicrobial resistance and outcomes in critically ill patients with pseudomonal infection.MethodsPatients with PA isolated during ICU admission from 2013–2016 were identified using provincial microbiology data. Patients were classified as colonized or infected. Those with infection were reviewed for source of infection, patient characteristics, antimicrobial susceptibilities, appropriateness of empiric antimicrobial therapy and 30-day mortality. Independent predictors of mortality were identified using multivariable logistic regression.ResultsA total of 196 unique patients were culture-positive for PA. 140 (71%) were infected and included for analysis. Mean patient age was 55.4 years (18.4 SD) and 62% were male. Admission categories included medical (71%), surgical (20%), and trauma or neurological (9%). Mean APACHE II score at the time of ICU admission was 19.4 (9.8 SD). One hundred and twenty-six (90%) patients required invasive mechanical ventilation, 102 (73%) vasopressor support and 27 (19%) new initiation of renal replacement therapy. Thirty-two (23%) died within 30 days of ICU admission. The median ICU length of stay was 13 days (IQR 5–27). Median time to infection was 1 day (IQR 0–9). Sources were respiratory (66%) followed by skin/soft tissue (11%), urinary (10%), and blood (5%). Twenty (14%) isolates were multi-drug-resistant (MDR) and six (4%) were extensively drug resistant (XDR). There were no pan-resistant isolates. One hundred and one (52%) of infections were nosocomial. Empiric antimicrobial therapy was effective in 97 (69%) cases. On multivariable analysis liver disease (aOR 6.2, 95% CI 1.5–25.7; P = 0.01), malignancy (aOR 5.0, 95% CI 1.5–17.3; P = −0.01) and higher APACHE II score at the time of admission (aOR 1.1, 95% CI 1.0–1.1; P = 0.02), were independently associated with 30-day mortality.ConclusionPA in the ICU is associated with substantial mortality and is most commonly isolated from the respiratory tract. Existing malignancy, liver disease and higher APACHE II score at admission were independently associated with mortality.Disclosures All authors: No reported disclosures.

Impact of Socioeconomic Status on 30-Day and 1-Year Mortalities after Intensive Care Unit Admission in South Korea: A Retrospective Cohort Study.

BackgroundSocioeconomic status (SES) is closely associated with health outcomes, including mortality in critically ill patients admitted to intensive care unit (ICU). However, research regarding this issue is lacking, especially in countries where the National Health Insurance System is mainly responsible for health care. This study aimed to investigate how the SES of ICU patients in South Korea is associated with mortality.MethodsThis was a retrospective observational study of adult patients aged ≥20 years admitted to ICU. Associations between SES-related factors recorded at the time of ICU admission and 30-day and 1-year mortalities were analyzed using univariable and multivariable Cox regression analyses.ResultsA total of 6,008 patients were included. Of these, 394 (6.6%) died within 30 days of ICU admission, and 1,125 (18.7%) died within 1 year. Multivariable Cox regression analysis found no significant associations between 30-day mortality after ICU admission and SES factors (P>0.05). However, occupation was significantly associated with 1-year mortality after ICU admission.ConclusionsOur study shows that 30-day mortality after ICU admission is not associated with SES in the National Health Insurance coverage setting. However, occupation was associated with 1-year mortality after ICU admission.

Exploring the Potential Effectiveness of Combining Optimal Nutrition With Electrical Stimulation to Maintain Muscle Health in Critical Illness: A Narrative Review.

Muscle wasting occurs rapidly within days of an admission to the intensive care unit (ICU). Concomitant muscle weakness and impaired physical functioning can ensue, with lasting effects well after hospital discharge. Early physical rehabilitation is a promising intervention to minimize muscle weakness and physical dysfunction. However, there is an often a delay in commencing active functional exercises (such as sitting on the edge of bed, standing and mobilizing) due to sedation, patient alertness, and impaired ability to cooperate in the initial days of ICU admission. Therefore, there is high interest in being able to intervene early through nonvolitional exercise strategies such as electrical muscle stimulation (EMS). Muscle health characterized as the composite of muscle quantity, as well as functional and metabolic integrity, may be potentially maintained when optimal nutrition therapy is provided in complement with early physical rehabilitation in critically ill patients; however, the type, dosage, and timing of these interventions are unclear. This article explores the potential role of nutrition and EMS in maintaining muscle health in critical illness. Within this article, we will evaluate fundamental concepts of muscle wasting and evaluate the effects of EMS, as well as the effects of nutrition therapy on muscle health and the clinical and functional outcomes in critically ill patients. We will also highlight current research gaps in order to advance the field forward in this important area.

Dynamic association of plasma brain-derived neurotrophic factor, neuron-specific enolase, and S100β with delirium in critically ill patients

Objective To determine the association between plasma concentrations of brain derived neurotrophic factor (BDNF), neuron-specific enolase (NSE), and S100β, and the occurrence of delirium in critically ill patients. Methods Totally 65 patients in Intensive Care Unit (ICU) of Wuxi People’s Hospital of Nanjing Medical University between June 2015 and February 2016 were included in the present study. Delirium diagnosis was used by confusion assessment method for the ICU (CAM-ICU). Plasma BDNF, NSE, and S100β concentrations were determined on day 1(T1), 3(T3), and 10(T10) after ICU admission. The day of ICU admission was defined as T0. Results Compared with the plasma BDNF level on T1 (0.23±0.22) μg/L, the plasma BDNF level on T3 (0.59±0.34) μg/L and T10 (0.24±0.21) μg/L were higher, especially for that on T3 with a significant difference (F=21.58, P=0.018). Plasma NSE level on T3 (1.68±0.25) μg/L was significantly higher than that on T1 (1.22±0.32) μg/L (F=10.24, P=0.042). Compared with those without delirium, the delirious patients had lower BDNF, higher NSE and S100β on T1, T3 and T10, of which the difference of BDNF [T1: (0.23±0.22) μg/L vs. (1.02±0.24) μg/L, F=116.25, P<0.01; T3: (0.59±0.34) μg/L vs. (1.55±0.36) μg/L, F=82.39, P<0.01; T10: (0.24±0.21) μg/L vs. (1.09±0.55) μg/L, F=50.93, P=0.003, and NSE (T1: (1.22±0.32) μg/L vs. (0.47±0.23) μg/L, F=94.30, P<0.01; T3:(1.68±0.25) μg/L vs. (0.79±0.28) μg/L, F=78.63, P=0.017; T10: (0.98±0.37) μg/L vs. (0.51±0.22) μg/L, F=70.95, P=0.026) reached significant differences. Conclusions Plasma BDNF and NSE are closely related to the occurrence of delirium in critically ill patients, especially for BDNF. Clinical monitoring of plasma levels of BDNF can help to predict the outcome of brain function in critically ill patients. Key words: Brain derived neurotrophic factor; Neuron-specific enolase; Plasma; Critically ill patients; Delirium; Dynamic alteration; Brain function; Outcome

Using artificial intelligence to predict prolonged mechanical ventilation and tracheostomy placement

BackgroundEarly identification of critically ill patients who will require prolonged mechanical ventilation (PMV) has proven to be difficult. The purpose of this study was to use machine learning to identify patients at risk for PMV and tracheostomy placement. Materials and methodsThe Multiparameter Intelligent Monitoring in Intensive Care III database was queried for all intensive care unit (ICU) stays with mechanical ventilation. PMV was defined as ventilation >7 d. Classifiers with a gradient-boosted decision trees algorithm were created for the outcomes of PMV and tracheostomy placement. The variables used were six different severity-of-illness scores calculated on the first day of ICU admission including their components and 30 comorbidities. Mean receiver operating characteristic curves were calculated for the outcomes, and variable importance was quantified. ResultsThere were 20,262 ICU stays identified. PMV was required in 13.6%, and tracheostomy was performed in 6.6% of patients. The classifier for predicting PMV was able to achieve a mean area under the curve (AUC) of 0.820 ± 0.016, and tracheostomy was predicted with an AUC of 0.830 ± 0.011. There were 60.7% patients admitted to a surgical ICU, and the classifiers for these patients predicted PMV with an AUC of 0.852 ± 0.017 and tracheostomy with an AUC of 0.869 ± 0.015. The variable with the highest importance for predicting PMV was the logistic organ dysfunction score pulmonary component (13%), and the most important comorbidity in predicting tracheostomy was cardiac arrhythmia (12%). ConclusionsThis study demonstrates the use of artificial intelligence through machine-learning classifiers for the early identification of patients at risk for PMV and tracheostomy. Application of these identification techniques could lead to improved outcomes by allowing for early intervention.

The impact of reducing intensive care unit length of stay on hospital costs: evidence from a tertiary care hospital in Canada

To use theoretical modelling exercises to determine the effect of reduced intensive care unit (ICU) length of stay (LOS) on total hospital costs at a Canadian centre. We conducted a retrospective cost analysis from the perspective of one tertiary teaching hospital in Canada. Cost, demographic, clinical, and LOS data were retrieved through case-costing, patient registry, and hospital abstract systems of The Ottawa Hospital Data Warehouse for all new in-patient ward (30,483) and ICU (2,239) encounters between April 2012 and March 2013. Aggregate mean daily variable direct (VD) costs for ICU vs ward encounters were summarized by admission day number, LOS, and cost centre. The mean daily VD cost per ICU patient was $2,472 (CAD), accounting for 67.0% of total daily ICU costs per patient and $717 for patients admitted to the ward. Variable direct cost is greatest on the first day of ICU admission ($3,708), and then decreases by 39.8% to plateau by the fifth day of admission. Reducing LOS among patients with ICU stays ≥ four days could potentially result in an annual hospital cost saving of $852,146 which represents 0.3% of total in-patient hospital costs and 1.2% of ICU costs. Reducing ICU LOS has limited cost-saving potential given that ICU costs are greatest early in the course of admission, and this study does not support the notion of reducing ICU LOS as a sole cost-saving strategy.

Hypophosphatemia is associated with poor prognosis of critically ill patients: a meta-analysis of 1 555 patients

To evaluate the relationship between hypophosphatemia and prognosis in critically ill patients. Some hypophosphatemia-associated prospective or retrospective clinical cohort studies were searched through CNKI, Wanfang Data, PubMed, Embase, Cochrane library, and Google Scholar English database respectively, with the guidance of these key words such as hypophosphatemia, intensive care, prognosis and fatality rate. The articles were concerned about the correlation between hypophosphatemia and the prognosis of patients in intensive care unit (ICU). The literatures collected were restricted from the creation of data base to April 2017. The mean value of < 0.8 mmol/L in serum phosphorus concentrations of the patients within the first 2 days of ICU admission would be treated as the diagnostic criteria of hypophosphatemia. Literature qualities were assessed by Newcastle-Ottawa scale (NOS). Meta-analysis was carried out by RevMan 5.3, and the sensitivity analysis was performed to test the stability of the meta-analysis. The existence of bias was analyzed by using the funnel graph analysis. Ten articles were ultimately included in the analysis, including 9 in Chinese and 1 in English, all of which were high qualities. 1 555 patients were involved in these clinical studies, of whom 606 patients had hypophosphatemia and other 949 were normal phosphatemia. Meta analysis results showed that patients with hypophosphatemia had higher acute physiology and chronic health evaluation II (APACHE II) score as compared with that of normal phosphatemia group [standardized mean difference (SMD) = 0.64, 95% confidence interval (95%CI) = 0.24-1.04, P = 0.002]. Subgroup analysis showed that APACHE II score increased in mild, moderate and severe hyperphosphatemia subgroups, and there were significant differences between any two subgroups (all P < 0.01). Longer duration of mechanical ventilation (SMD = 0.50, 95%CI = 0.23-0.78, P = 0.000 3) and the length of ICU stay (SMD = 0.36, 95%CI = 0.06-0.67, P = 0.02), and even higher ICU mortality [odds ratio (OR) = 2.99, 95%CI = 2.09-4.27, P < 0.000 01] were seen in patients with hypophosphatemia as compared with normal phosphatemia patients. However, serum creatinine (SCr) levels (SMD = -0.19, 95%CI = -2.76-2.39, P = 0.89) and serum albumin (Alb) level (SMD = -0.63, 95%CI = -1.54-0.27, P = 0.17) were all similar between hypophosphatemic group and normal phosphatemia group. Sensitivity analysis excluded the effect of heterogeneity on statistical results. The funnel graphics were basically symmetrical, which indicated that the included literatures were distributed well, and the publication bias was small. Occurrence of hypophosphatemia in ICU patients is associated with severity of illness, prolonged duration of MV and length of ICU stay, and higher mortalities. Levels of serum phosphorus may have certain clinical values for assessing prognosis of ICU patients.

Factors associated with mortality among patients with active pulmonary tuberculosis requiring intensive care.

The aim of this study was to identify patient characteristics and risk factors associated with in-hospital mortality of patients with pulmonary tuberculosis (PTB) requiring intensive care unit (ICU) management. A retrospective chart review was conducted of all patients with active PTB admitted to the ICU at Singapore General Hospital, Singapore, between January 2005 and December 2010. There were 2,155 patients with active PTB diagnosed, of whom 83 (3.9%) patients were admitted to the ICU, but eight were excluded because their admission to the ICU was unrelated to PTB. The most common comorbidities were diabetes mellitus (n = 23, 30.7%) and immunocompromised host (n = 25, 33.3%). A few (n = 4, 5.3%) of the patients had HIV coinfection. A majority (n = 67, 89.3%) of patients required mechanical ventilation and the mean duration of mechanical ventilation was 8.05 ± 14.43 days. Mean duration of ICU stay and hospital stay were 10.23 ± 15.8 days and 33.7 ± 50.7 days, respectively. In-hospital mortality was 62.7% (n = 47), and 36 of these patients died while in the ICU (ICU mortality, 48.0%). Univariate analysis identified ischaemic heart disease, low albumin, Acute Physiology and Chronic Health Evaluation score, disseminated intravascular coagulation, shock and multiorgan failure as significantly associated with mortality. Multivariate analysis showed that low albumin on the day of ICU admission was the only significant independent predictor of death (p = 0.033). In-hospital mortality from active PTB requiring ICU admission was 62.7%, and low albumin was an independent predictor of mortality in this study.

Association of positive fluid balance and mortality in sepsis and septic shock in an Australian cohort.

In patients with septic shock, a correlation between positive fluid balance and worsened outcomes has been reported in multiple observational studies worldwide. No published data exists in an Australasian cohort. We set out to explore this association in our institution. We conducted a retrospective audit of patient records from August 2012 to May 2015 in a single-centre, 24-bed surgical and medical intensive care unit (ICU) in Sydney, Australia. All patients with septic shock were included. Exclusion criteria included length of stay less than 24 hours or vasopressors needed for less than six hours. Data was gathered on fluid balance for the first seven days of ICU admission, biochemical data and other clinical indices. The primary outcome measure was survival to hospital discharge. One hundred and eighty-six patients with septic shock were included, with an overall hospital mortality of 23.7%. Seventy-five percent of patients required mechanical ventilation, and 27.4% required haemodialysis. The mean daily fluid balance on the first day of admission was positive 1,424 ml and 1,394 ml for ICU and hospital survivors, respectively. On average, the daily fluid balance for non-survivors was higher than the survivors: ICU non-survivors were 602 (95% confidence intervals 230, 974) ml (<i>P</i>=0.0015) and hospital non-survivors were 530 [95% confidence intervals 197, 863] ml (<i>P</i>=0.0017) more than the survivors. In line with other recently published data, after adjustment for confounders (severity of illness based on the Acute Physiology and Chronic Health Evaluation score) we found a correlation between positive fluid balance and worsened hospital mortality in critically ill patients with sepsis and septic shock. Further research investigating rational use of fluids in this patient group is needed.

Circulating levels of soluble Fas (sCD95) are associated with risk for development of a nonresolving acute kidney injury subphenotype

BackgroundCritically ill patients with acute kidney injury (AKI) can be divided into two subphenotypes, resolving or nonresolving, on the basis of the trajectory of serum creatinine. It is unknown if the biology underlying these two AKI recovery patterns is different.MethodsWe measured eight circulating biomarkers in plasma obtained from a cohort of patients admitted to an intensive care unit (ICU) (n = 1241) with systemic inflammatory response syndrome. The biomarkers were representative of several biologic processes: apoptosis (soluble Fas), inflammation (soluble tumor necrosis factor receptor 1, interleukin 6, interleukin 8) and endothelial dysfunction, (angiopoietin 1, angiopoietin 2, and soluble vascular cell adhesion molecule 1). We tested for associations between biomarker levels and AKI subphenotypes using relative risk regression accounting for multiple hypotheses with the Bonferroni correction.ResultsDuring the first 3 days of ICU admission, 868 (70%) subjects developed AKI; 502 (40%) had a resolving subphenotype, and 366 (29%) had a nonresolving subphenotype. Hospital mortality was 12% in the resolving subphenotype and 21% in the nonresolving subphenotype. Soluble Fas was the only biomarker associated with a nonresolving subphenotype after adjustment for age, body mass index, diabetes, and Acute Physiology and Chronic Health Evaluation III score (p = 0.005).ConclusionsIdentifying modifiable targets in the Fas-mediated pathway may lead to strategies for prevention and treatment of a clinically important form of AKI.

The Host Response in Patients with Sepsis Developing Intensive Care Unit-acquired Secondary Infections.

Sepsis can be complicated by secondary infections. We explored the possibility that patients with sepsis developing a secondary infection while in the intensive care unit (ICU) display sustained inflammatory, vascular, and procoagulant responses. To compare systemic proinflammatory host responses in patients with sepsis who acquire a new infection with those who do not. Consecutive patients with sepsis with a length of ICU stay greater than 48 hours were prospectively analyzed for the development of ICU-acquired infections. Twenty host response biomarkers reflective of key pathways implicated in sepsis pathogenesis were measured during the first 4 days after ICU admission and at the day of an ICU-acquired infection or noninfectious complication. Of 1,237 admissions for sepsis (1,089 patients), 178 (14.4%) admissions were complicated by ICU-acquired infections (at Day 10 [6-13], median with interquartile range). Patients who developed a secondary infection showed higher disease severity scores and higher mortality up to 1 year than those who did not. Analyses of biomarkers in patients who later went on to develop secondary infections revealed a more dysregulated host response during the first 4 days after admission, as reflected by enhanced inflammation, stronger endothelial cell activation, a more disturbed vascular integrity, and evidence for enhanced coagulation activation. Host response reactions were similar at the time of ICU-acquired infectious or noninfectious complications. Patients with sepsis who developed an ICU-acquired infection showed a more dysregulated proinflammatory and vascular host response during the first 4 days of ICU admission than those who did not develop a secondary infection.

The role of propionic acid at diagnosis predicts mortality in patients with septic shock

PurposeThis study aims to assess the diagnostic and prognostic value of propionic acid in patients with septic shock on a medical intensive care unit (ICU). MethodsSerum propionic acid and clinical common cytokines levels were measured within 24h after the diagnosis of sepsis, and the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, and Mortality were recorded in ICU. A 28-day and 90-day follow-up was performed for all patients. ResultsA total of 118 septic patients were enrolled in this study. The propionic acid was higher in patients with septic shock compared with sepsis. Multivariate logistic regression analysis showed that propionic acid was independent predictor of sepsis (odds ratio: 1.279; 95% confidence interval: 1.069–1.530; P=0.007) and septic shock (odds ratio: 1.859; 95% confidence interval: 1.342–2.576; P<0.001) and ICU mortality (odds ratio: 1.331; 95% confidence interval: 1.107–1.600; P=0.002), 28-day mortality (odds ratio: 1.259; 95% confidence interval: 1.046–1.514; P=0.015) and 90-day mortality (odds ratio: 1.304; 95% confidence interval: 1.092–1.558; P=0.003). The receiver operating characteristic curve (AUC) analysis showed the areas under of propionic acid on ICU admission day for predicting sepsis and septic shock were 0.773 and 0.85 respectively, the areas under of propionic acid for predicting ICU mortality, 28-d and 90-d mortality were 0.779, 0.739 and 0.809 respectively. Using a PA cutoff of 0.053 and 0.095 for predicting sepsis and septic shock respectively, the sensitivity was 97.62% and 85.5%, and the specificity was 58% and 83.5%, respectively. Using a PA cutoff of 0.139 for predicting ICU mortality, 28- and 90-day mortality, the sensitivity was 69.39%, 67.44% and 69.09% respectively, and the specificity was 78.26%, 73.33% and 82.54% respectively. ConclusionsPropionic acid showed diagnostic capacity to diagnose septic shock and revealed prognostic information for mortality.

112 OUTCOMES OF RENAL REPLACEMENT THERAPY IN INTENSIVE CARE UNITS IN THAILAND

Category: Epidemiology and Outcomes from AKI Presenter: Dr SADUDEE PEERAPORNRATANA Keywords: renal replacement therapy, acute kidney injury, intensive care unit, Thailand, outcome Severe acute kidney injury (AKI) requiring renal replacement therapy (RRT) is a common complication in intensive care unit (ICU) patients and associated with high mortality and other bad outcomes. However, the epidemiologic data and outcome of RRT in ICU in Southeast Asia region including Thailand are still lacking. The objectives of this study is to determine the epidemiology and outcomes of RRT in ICU in Thailand. This is the analysis from a prospective cohort study (SEA-AKI study). Data was collected from nine ICUs in secondary and tertiary care centers across Thailand from January 2014 to June 2015. The patients with end-stage renal disease were excluded from analysis. A total of 2,646 patients were admitted in ICUs, 53.3% (1,345 patients) had AKI. About 19.4% of AKI patients (262 patients) undergone RRT. The median time form ICU admission to RRT initiation was 2 days. The median RRT duration was 3 days. Intermittent HD and CRRT were the two most common RRT modalities used in ICU. The mortality in ICU was significant higher in patients undergone RRT compared to patient with no RRT (46.9% vs 31.4%, p <0.001). The in-hospital mortality was also higher in patients undergone RRT significantly (61.0% vs 40.7%, p <0.001). The median length of stay in ICU and hospital were significant longer in AKI patients who needed RRT (7 days vs 5 days, p <0.001; and 19 days vs 13 days, p <0.001; respectively). The ventilator days in patients who needed RRT were significant longer (7 days vs 4 days, p <0.001). Factors associated with RRT in ICU from multivariable analysis were underlying diabetes (OR 1.67, 95% CI 1.08-2.58), SOFA (OR 1.18, 95% CI 1.10-1.28) and serum creatinine (OR 1.15, 95% CI 1.07-1.24) on the day of ICU admission. RRT in ICU associated with high morbidity and mortality. Factors associated with RRT in ICU from multivariable analysis were underlying diabetes, SOFA score and serum creatinine on the day of ICU admission.

Follow-up chest radiographic findings in patients with MERS-CoV after recovery.

Purpose:To evaluate the follow-up chest radiographic findings in patients with Middle East respiratory syndrome coronavirus (MERS-CoV) who were discharged from the hospital following improved clinical symptoms.Materials and Methods:Thirty-six consecutive patients (9 men, 27 women; age range 21–73 years, mean ± SD 42.5 ± 14.5 years) with confirmed MERS-CoV underwent follow-up chest radiographs after recovery from MERS-CoV. The 36 chest radiographs were obtained at 32 to 230 days with a median follow-up of 43 days. The reviewers systemically evaluated the follow-up chest radiographs from 36 patients for lung parenchymal, airway, pleural, hilar and mediastinal abnormalities. Lung parenchyma and airways were assessed for consolidation, ground-glass opacity (GGO), nodular opacity and reticular opacity (i.e., fibrosis). Follow-up chest radiographs were also evaluated for pleural thickening, pleural effusion, pneumothorax and lymphadenopathy. Patients were categorized into two groups: group 1 (no evidence of lung fibrosis) and group 2 (chest radiographic evidence of lung fibrosis) for comparative analysis. Patient demographics, length of ventilations days, number of intensive care unit (ICU) admission days, chest radiographic score, chest radiographic deterioration pattern (Types 1-4) and peak lactate dehydrogenase level were compared between the two groups using the student t-test, Mann-Whitney U test and Fisher's exact test.Results:Follow-up chest radiographs were normal in 23 out of 36 (64%) patients. Among the patients with abnormal chest radiographs (13/36, 36%), the following were found: lung fibrosis in 12 (33%) patients GGO in 2 (5.5%) patients, and pleural thickening in 2 (5.5%) patients. Patients with lung fibrosis had significantly greater number of ICU admission days (19 ± 8.7 days; P value = 0.001), older age (50.6 ± 12.6 years; P value = 0.02), higher chest radiographic scores [10 (0-15.3); P value = 0.04] and higher peak lactate dehydrogenase levels (315-370 U/L; P value = 0.001) when compared to patients without lung fibrosis.Conclusion:Lung fibrosis may develop in a substantial number of patients who have recovered from Middle East respiratory syndrome coronavirus (MERS-CoV). Significantly greater number of ICU admission days, older age, higher chest radiographic scores, chest radiographic deterioration patterns and peak lactate dehydrogenase levels were noted in the patients with lung fibrosis on follow-up chest radiographs after recovery from MERS-CoV.

Reduced rate of intensive care unit acquired gram-negative bacilli after removal of sinks and introduction of \u2018water-free\u2019 patient care

BackgroundSinks in patient rooms are associated with hospital-acquired infections. The aim of this study was to evaluate the effect of removal of sinks from the Intensive Care Unit (ICU) patient rooms and the introduction of ‘water-free’ patient care on gram-negative bacilli colonization rates.MethodsWe conducted a 2-year pre/post quasi-experimental study that compared monthly gram-negative bacilli colonization rates pre- and post-intervention using segmented regression analysis of interrupted time series data. Five ICUs of a tertiary care medical center were included. Participants were all patients of 18 years and older admitted to our ICUs for at least 48 h who also received selective digestive tract decontamination during the twelve month pre-intervention or the twelve month post-intervention period. The effect of sink removal and the introduction of ‘water-free’ patient care on colonization rates with gram-negative bacilli was evaluated. The main outcome of this study was the monthly colonization rate with gram-negative bacilli (GNB). Yeast colonization rates were used as a ‘negative control’. In addition, colonization rates were calculated for first positive culture results from cultures taken ≥3, ≥5, ≥7, ≥10 and ≥14 days after ICU-admission, rate ratios (RR) were calculated and differences tested with chi-squared tests.ResultsIn the pre-intervention period, 1496 patients (9153 admission days) and in the post-intervention period 1444 patients (9044 admission days) were included. Segmented regression analysis showed that the intervention was followed by a statistically significant immediate reduction in GNB colonization in absence of a pre or post intervention trend in GNB colonization. The overall GNB colonization rate dropped from 26.3 to 21.6 GNB/1000 ICU admission days (colonization rate ratio 0.82; 95%CI 0.67–0.99; P = 0.02). The reduction in GNB colonization rate became more pronounced in patients with a longer ICU-Length of Stay (LOS): from a 1.22-fold reduction (≥2 days), to a 1.6-fold (≥5 days; P = 0.002), 2.5-fold (for ≥10 days; P < 0.001) to a 3.6-fold (≥14 days; P < 0.001) reduction.ConclusionsRemoval of sinks from patient rooms and introduction of a method of ‘water-free’ patient care is associated with a significant reduction of patient colonization with GNB, especially in patients with a longer ICU length of stay.

Optimal Energy Delivery, Rather than the Implementation of a Feeding Protocol, May Benefit Clinical Outcomes in Critically Ill Patients.

Malnutrition is common in intensive care units (ICU), and volume based feeding protocols have been proposed to increase nutrient delivery. However, the volume based approach compared to trophic feeding has not been proven entirely successful in critically ill patients. Our study aimed to compare the clinical outcomes both before and after the implementation of the feeding protocol, and to also evaluate the effects of total energy delivery on outcomes in these patients. We retrospectively collected all patient data, one year before and after the implementation of the volume-based feeding protocol, in the ICU at Taichung Veterans General Hospital. Daily actual energy intake from enteral nutritional support was recorded from the day of ICU admission until either the 7th day of ICU stay, or the day of discharge from the ICU. The energy achievement rate (%) was calculated as: (actual energy intake/estimated energy requirement) × 100%. Two-hundred fourteen patients were enrolled before the implementation of the volume-based feeding protocol (pre-FP group), while 198 patients were enrolled after the implementation of the volume-based feeding protocol (FP group). Although patients in the FP group had significantly higher actual energy intakes and achievement rates when compared with the patients in the pre-FP group, there was no significant difference in mortality rate between the two groups. Comparing survivors and non-survivors from both groups, an energy achievement rate of less than 65% was associated with an increased mortality rate after adjusting for potential confounders (odds ratio, 1.6, 95% confidence interval, 1.01–2.47). The implementation of the feeding protocol could improve energy intake for critically ill patients, however it had no beneficial effects on reducing the ICU mortality rate. Receiving at least 65% of their energy requirements is the main key point for improving clinical outcomes in patients.

Clinical Significance of Bioimpedance Spectroscopy in Critically Ill Patients.

Early fluid resuscitation is a key aspect in the successful management of critically ill patients, but the optimal goal for volume control after the acute stage of critical illness remains unclear. This study aimed to evaluate the prognostic value of bioimpedance spectrometry for fluid management in critically ill patients. In this prospective observational study, patients who consented to participate were screened within the first 24 hours of admission to a medical intensive care unit (ICU) from February 4, 2015, to January 31, 2016. Information on demographics, comorbidities, primary reasons for admission, baseline laboratory data, and ventilator or inotropic use were documented. Data of fluid intake, fluid output, and body weight were recorded for the first 3 days of ICU admission. Bioimpedance spectrometry was performed on the first and third days after ICU admission. All participants were followed until death or hospital discharge. Of the 140 enrolled patients (median age: 70 years, interquartile range: 60-77 years), 23 (16.4%) patients died during hospitalization. Independent predictors of hospital mortality were Acute Physiology and Chronic Health Evaluation II scores (per 1 point increase, odds ratio [OR]: 1.101) and overhydration (OH) volume on the first day (per 1 L increase, OR: 1.216). Compared to normal OH status (OH volume between -1 and 1 L), hyper OH status (OH volume < -1 L) on the third day after ICU admission was an independent predictor of hospital death (OR: 7.609). Normal OH status on the third day was associated with greater numbers of ICU-free and ventilator-free days. Bioimpedance spectrometry can be used to predict outcomes in critically ill patients. Increased OH volume on day 1 and hyper OH volume on day 3 of ICU admission are associated with a greater risk of hospital mortality. Volume status on day 3 is associated with durations of ventilator use and ICU stay.