Day Of Intensive Care Unit Discharge Research Articles

Temperature Profile and Adverse Outcomes After Discharge From the Intensive Care Unit.

A predictive model that uses the rhythmicity of core body temperature (CBT) could be an easily accessible clinical tool to ultimately improve outcomes among critically ill patients. To assess the relation between the 24-hour CBT profile (CBT-24) before intensive care unit (ICU) discharge and clinical events in the step-down unit within 7 days of ICU discharge. This retrospective cohort study in a tertiary ICU at a single center included adult patients requiring acute invasive ventilation for more than 48 hours and assessed major clinical adverse events (MCAEs) and rapid response system activations (RRSAs) within 7 days of ICU discharge (MCAE-7 and RRSA-7, respectively). The 291 enrolled patients had a median mechanical ventilation duration of 139 hours (IQR, 50-862 hours) and at admission had a median Acute Physiology and Chronic Health Evaluation II score of 22 (IQR, 7-42). At least 1 MCAE or RRSA occurred in 64% and 22% of patients, respectively. Independent predictors of an MCAE-7 were absence of CBT-24 rhythmicity (odds ratio, 1.78 [95% CI, 1.07-2.98]; P = .03), Sequential Organ Failure Assessment score at ICU discharge (1.10 [1.00-1.21]; P = .05), male sex (1.72 [1.04-2.86]; P = .04), age (1.02 [1.00-1.04]; P = .02), and Charlson Comorbidity Index (0.87 [0.76-0.99]; P = .03). Age (1.03 [1.01-1.05]; P = .006), sepsis at ICU admission (2.02 [1.13-3.63]; P = .02), and Charlson Comorbidity Index (1.18 [1.02-1.36]; P = .02) were independent predictors of an RRSA-7. Use of CBT-24 rhythmicity can assist in stratifying a patient's risk of subsequent deterioration during general care within 7 days of ICU discharge.

A Prospective Study Evaluating Sleep Quality and Disorders in Post-ARDS Patients.

IntroductionCritically ill patients are predisposed to developing sleep disorders due to multiple factors like pre-existing sleep disorders, severe acute illness, sleep-altering medical interventions, and the disturbing intensive care unit (ICU) environment. In the current study, a multi-modality approach has been attempted to capture the different aspects of sleep disturbances, including insomnia (using ISI), daytime sleepiness (using ESS), sleep quality (using PSQI), sleep architecture, and SDB (using PSG).Materials and MethodsThe eligible ARDS survivor patients were updated about the study's design prior to hospital discharge. At admission, data regarding demographic details, clinical history, etiology of ARDS, and PaO2/FiO2 (P/F) ratio at presentation, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores was collected. All enrolled patients were evaluated twice (early-within 7 days of admission and late-after 6 weeks of discharge) by the Richards–Campbell Sleep Questionnaire (RCSQ), Insomnia severity index (ISI), and level 1 PSG. Additionally, ESS questionnaire and the Pittsburgh Sleep Quality Index (PSQI) were also recorded in late evaluation. Abnormal sleep was defined if one or more of the following characteristics met: ISI > 15, ESS > 10, global PSQI > 5, AHI ≥ 5 events/h.ResultsThirty patients were recruited out of the total of 88 ARDS patients screened at admission. The median (IQR) PaO2/FiO2 ratio and APACHE II scores were 176 (151–191.5) and 14 (14–16), respectively. The median (IQR) duration of stay in the ICU was 10 (7.3–19.5) days. The median RCSQ score in the early and late evaluation was 42 and 69, respectively. The mean ISI score in the early evaluation was 16.67 ± 4.72, which decreased to 11.70 ± 5.03 in late evaluation (p < 0.05). ISI score > 15 (clinical insomnia) was found in 18 out of 30 subjects (60%) in early evaluation and 11 out of 30 (36%) in late evaluation. During the early evaluation, sleep efficiency was low (median 59.9% and predominantly N1 and N2) which improved in late evaluation (median 80.6%). Of the 30 patients, only 4 had AHI > 5 in early evaluation and none in late evaluation. Neither of P/F ratio, SOFA, and APACHE II scores did correlate with ICU events in the early and late evaluations. Regression analysis showed subjects with ICU stay more than 10 days, duration of IMV more than 7 days, Fentanyl more than 7 mg, duration of sedative use more than 7 days was independently associated with poor objective sleep quality (low sleep efficiency, low TST and high arousal index) during the early and late evaluations after ICU discharge compared to counterparts (p value < 0.05).ConclusionWe conclude that sleep quality in ARDS survivors was poor within 7 days of ICU discharge, characterized by severe disruption of sleep architecture and sleep-disordered breathing. After 6 weeks of ICU discharge sleep quality showed significant improvement in the N3 stage and AHI, however persistent insomnia was observed even at 6 weeks. Therefore, prior identification of risk factors and early diagnosis of sleep quality disorders in post-ARDS patients is essential.

Acquired Platelet GPVI Dysfunction As Possible Predictor for Early Sepsis Diagnosis and Poor Outcome

Introduction: Sepsis is a major contributor to the global disease burden with estimated 20 million cases per year. With every hour prior to begin of therapy mortality increases by over 7%. Hence, early diagnosis is indispensable for patient survival, though it is hampered by the lack of known pathognomonic symptoms. Sepsis diagnosis is set according to an increase of the sequential organ failure assessment (SOFA) score, reflecting organ dysfunction. Severe symptoms comprising dysfunctional hemostasis are disseminated intravascular coagulation and formation of massive edema due to loss of vascular integrity. Functional hemostasis and maintenance of vascular integrity depends particularly on the platelet surface receptor glycoprotein (GP)VI that dimerizes upon activation and transduces its signals via the associated immunoreceptor tyrosine activation motif (ITAM) of the Fc-gamma chain. Sepsis-associated thrombocytopenia has been extensively investigated and low platelet counts are implemented in the SOFA score.Platelet function during sepsis, however, remains ill-defined with few reports using ADP or thrombin receptor activating peptide (TRAP) and overall conflicting results. Objectives: We assessed platelet function in patients with sepsis III criteria in a single center study at three times during disease: (I) intensive care unit (ICU) admission day; (II) day five to seven at ICU; (III) day of ICU discharge. Methods: Fifteen patients were recruited from the ICU of the University Hospital Würzburg, Germany (m:f ratio 9:6; median age 70; mortality: 40%). Platelets in whole blood were stimulated with ADP, TRAP, or the GPVI agonist collagen-related peptide (CRP). Activation was detected flow cytometrically by P-selectin (CD62P) exposure and integrin GPIIb/IIIa activation (PAC-1 binding). Results were correlated with light transmission aggregometry (LTA) and immunoblotting of phospho-Syk and -LAT. Co-incubation experiments were performed with plasma, whole blood or patient-borne bacterial isolates comprising Gram-negative (E. coli, K. pneumoniae) or Gram-positive (E. faecalis) strains. Results: Platelet function was markedly reduced in all patients assessed by flow cytometry and LTA despite overall unaltered receptor expression. The defect was most prominent after GPVI stimulation with CRP(Mean Geo-MFI ± SD; Control: 9356 ± 3460; Sepsis: 1438 ± 2090; p&amp;lt;.0001). In 14/15 patients GPVI-dysfunction was already present at time (I). In contrast, only 7/15 patients were thrombocytopenic at this early time. We did not consistently find elevated GPVI ectodomain plasma levels, low platelet counts, increased mean platelet volume, or elevated reticulated platelet levels in our cohort at early time points and minor alterations only late during disease progression. We conclude that none of these is a bona fide biomarker, neither for early sepsis diagnosis nor as a prognostic marker. Sepsis platelets failed to transduce the GPVI signal to induce tyrosine phosphorylation of Syk kinase or LAT. ITIM receptor-based tyrosine phosphatases SHP1 and SHP2 were neither preactivated in resting platelets nor responsive to GPVI stimulation. Of note, platelet aggregation upon GPVI stimulation increased in those patients whose condition ameliorated. We found a strong correlation of restored platelet aggregation by LTA with survival and could distinguish survivors from non-survivors using this marker for stratification (%max aggregation ± SD; survivors: 25 ± 8%; non-survivors: 4 ± 3%; p&amp;lt;0.01). Responsiveness to CRP was unaltered when platelets of healthy donors were co-incubated with patient blood borne bacterial isolates. Platelet reactivity was also unaltered when they were pre-incubated in plasma of sepsis patients. However, pre-incubation in whole blood clearly diminished the response toward CRP,suggesting that the abrogated GPVI signaling is in part mediated by cellular components. Conclusion: Our results strongly imply that GPVI hypo-responsiveness could serve as a bona fide marker for early sepsis diagnosis and also bears potential to act as a prognostic indicator for therapy monitoring, independent from the source of infection. Acknowledgement: Financial support was granted by the Deutsche Forschungsgemeinschaft (374031971 - TRR 240). Disclosures No relevant conflicts of interest to declare.

Acute respiratory compromise on hospital wards: Association between recent ICU discharge and outcome

IntroductionAcute respiratory compromise (ARC), respiratory distress requiring emergent assisted ventilation, has a mortality of 20–40%. The relationship between recent discharge from an intensive care unit (ICU) and outcomes of patients suffering ARC on hospital wards is not well known. We hypothesized that a significant percentage of ARC events would occur in patients recently discharged from an ICU, that these patients would have worse outcomes than those without prior ICU stays, and that weekend ICU discharge would be associated with higher than expected post-ICU ARC frequency. MethodsUsing the Get-With-The-Guidelines-Resuscitation ARC registry, we included adult, index ARC events occurring on hospital wards. Our primary analysis used multivariable logistic regression accounting for clustering by hospital to examine the association between prior ICU discharge and survival after an ARC event. ResultsOf 11,800 ARCs, 937 (8%) occurred within two calendar days and 1010 (9%) >two calendar days after an ICU discharge. Patients with ICU discharge within two days had higher survival compared to those with no prior ICU stay (odds ratio 1.28 (95% CI: 1.11–1.48, p = 0.001)). Survival was not different in those with an ICU discharge more than two days prior and no prior ICU stay. Patients with ARC within two days of ICU discharge were not more likely to have left the ICU on a weekend. ConclusionsContrary to our hypothesis, discharge from an ICU within two calendar days was associated with better odds for survival compared to no prior ICU discharge or ICU discharge more than two days prior.

Effect of transcutaneous neuromuscular electrical stimulation on prevention of intensive care unit-acquired weakness in chronic obstructive pulmonary disease patients with mechanical ventilation

To evaluate the effect of transcutaneous neuromuscular electrical stimulation on prevention of intensive care unit-acquired weakness (ICU-AW) in chronic obstructive pulmonary disease (COPD) patients with mechanical ventilation. A prospective randomized controlled study was conducted. Sixty COPD patients aged 18-85 years old who were accepted mechanical ventilation therapy admitted to general intensive care unit (ICU) of the First Affiliated Hospital of Hunan University of Medicine from October 2017 to October 2018 were enrolled. Patients were divided into control group (n = 30) and intervention group (n = 30) by random number table method. All patients were accepted routine treatment, and on this basis, the intervention group was applied transcutaneous neuromuscular electrical stimulation on the extremities (twice a day, 30 minutes each time) after 24 hours of admission until ICU discharge. The Medical Research Council muscle strength score (MRC-Score), grip strength, incidence of ICU-AW on the 7th day after admission and on the day of ICU discharge; modified Barthel index score on the day of ICU discharge; and duration of mechanical ventilation, the length of ICU stay, and the length of hospital stay were compared between the two groups. Twenty-nine and 27 patients in the control group and the intervention group respectively finally completed the study in dividually. There was no significant difference in gender, age, Barthel index score before 2 weeks of ICU admission, body mass index or acute physiology and chronic health evaluation (APACHE) in ICU between the two groups. There was no significant difference in the MRC-Score, grip strength or incidence of ICU-AW on the 7th day after ICU admission between the two groups. Compared to the control group, the MRC-Score, grip strength and Barthel index score in the intervention group were significantly increased [MRC-Score: 55.97±8.43 vs. 46.32±7.36, grip strength (kg): 33.46±11.62 vs. 27.42±9.64, Barthel index score: 46.04±5.46 vs. 42.13±3.32, all P < 0.05], the incidence rate of ICU-AW was significantly decreased [7.4% (2/27) vs. 31.0% (9/29), P < 0.05], and duration of mechanical ventilation, the length of ICU stay, the length of hospital stay were significantly shortened [duration of mechanical ventilation (days): 5.12±2.01 vs. 7.24±4.35, the length of ICU stay (days): 8.34±2.36 vs. 10.45±2.62, the length of hospital stay (days): 13.21±2.21 vs. 15.38±3.67, all P < 0.05]. Transcutaneous neuromuscular electrical stimulation can effectively improve the muscle strength of COPD patients with mechanical ventilation and reduce the incidence of ICU-AW.

Development of a multivariable prediction model for identification of patients at risk for medication transfer errors at ICU discharge.

IntroductionDischarge from the intensive care unit (ICU) is a high-risk process, leading to numerous potentially harmful medication transfer errors (PH-MTE). PH-MTE could be prevented by medication reconciliation by ICU pharmacists, but resources are scarce, which renders the need for predicting which patients are at risk for PH-MTE. The aim of this study was to develop a prognostic multivariable model in patients discharged from the ICU to predict who is at increased risk for PH-MTE after ICU discharge, using predictors of PH-MTE that are readily available at the time of ICU discharge.Material and methodsData for this study were derived from the Transfer ICU Medication reconciliation study, which included ICU patients and scored MTE at discharge of the ICU. The potential harm of every MTE was estimated with a validated score, where after MTE with potential for harm were indicated as PH-MTE. Predictors for PH-MTE at ICU discharge were identified using LASSO regression. The c statisticprovided a measure of the overall discriminative ability of the prediction model and the prediction model was internally validated by bootstrap resampling. Based on sensitivity and specificity, the cut-off point of the prediction model was determined.ResultsThe cohort contained 258 patients and six variables were identified as predictors for PH-MTE: length of ICU admission, number of home medications and patient taking one of the following medication groups at home: vitamin/mineral supplements, cardiovascular medication, psycholeptic/analeptic medication and medication for obstructive airway disease. The c of the final prediction model was 0.73 (95%CI 0.67–0.79) and decreased to 0.62 according to bootstrap resampling. At a cut-off score of two the prediction model yielded a sensitivity of 70% and a specificity of 61%.ConclusionsA multivariable prediction model was developed to identify patients at risk for PH-MTE after ICU discharge. The model contains predictors that are available on the day of ICU discharge. Once external validation and evaluation of this model in daily practice has been performed, its incorporation into clinical practice could potentially allow institutions to identify patients at risk for PH-MTE after ICU discharge, on the day of ICU discharge, thus allowing for efficient, patient-specific allocation of clinical pharmacy services.Trial registrationDutch trial register: NTR4159, 5 September 2013, retrospectively registered.

Progressive mobility program and technology to increase the level of physical activity and its benefits in respiratory, muscular system, and functionality of ICU patients: study protocol for a randomized controlled trial

BackgroundEnhanced mobility in the Intensive Care Unit (ICU) could minimize the negative effects of critical illness, such as declines in cognitive, muscular, respiratory, and functional capacity. We aim to compare the functional status at ICU discharge of patients who underwent a progressive mobilization protocol versus patients who received conventional physiotherapy. We also examine the level of physical activity in the ICU, the degree of pulmonary and muscle function, and the length of stay to analyze correlations between these variables.MethodsThis is a protocol for a randomized controlled trial with blind evaluation. Ninety-six ICU patients will be recruited from a single center and randomly assigned to a control group or an intervention group. To determine the level of protocol activity the patient will receive, the patients’ ability to participate actively and their muscle strength will be considered. The protocol consists of five phases, ranging from passive therapies to walking and climbing stairs. The primary outcome will be the functional status at ICU discharge, measured with the Barthel Index and the ICU Mobility Scale (IMS). Measured secondary outcomes will include the level of physical activity, maximal inspiratory and expiratory pressures, forced expiratory volume in 1 second, maximum voluntary ventilation, handgrip strength, surface electromyography of the lower limb muscles, and results of the Timed Up and Go and 2-Minute Walk tests. Evaluations will be made within 2 days of ICU discharge except for the level of activity, which will be evaluated daily. Physiological variables and activity level will be analyzed by chi-square and t tests, according to the intention-to-treat paradigm.DiscussionMobility and exercise in the ICU should be undertaken with intensity, quantity, duration, and frequency adjusted according to the patients’ status. The results of this study may contribute to new knowledge of early mobility in the ICU, activity level, and varying benefits in critical patients, directing new approaches to physiotherapeutic interventions in these patients.Trial registrationRecruitment will begin in February 2017, and the expected completion date is August 2018. Patients are already being recruited.ClinicalTrials.gov, ID: NCT02889146. Registered on 3 March 2016.

Does the implementation of a novel intensive care discharge risk score and nurse-led inpatient review tool improve outcome? A prospective cohort study in two intensive care units in the UK

ObjectiveTo develop a clinical prediction model for poor outcome after intensive care unit (ICU) discharge in a large observational data set and couple this to an acute post-ICU ward-based review...

A study protocol for an observational cohort investigating COGnitive outcomes and WELLness in survivors of critical illness: the COGWELL study

IntroductionUp to 9 out of 10 intensive care unit (ICU) survivors will suffer some degree of cognitive impairment at hospital discharge and approximately half will have decrements that persist for...

Characteristics and Risk Factors of Trauma Patients Readmitted to the ICU Within the Same Hospitalization

There is little evidence about the characteristics and outcomes of unplanned intensive care unit (ICU) readmission for adult trauma patients. This retrospective study examined the characteristics, risks factors, and outcomes for trauma patients with and without ICU readmission. With 5 years of data, 1117 patients met inclusion criteria for the study. Patient characteristics for readmission included increased age and diabetes, while identified risk factors included increased time between injury and ICU admission, admission from surgery or outside hospital, higher Injury Severity Score, along with glucose, albumin, and lower Glasgow Coma Scale values on the day of ICU discharge.

Eosinopenia as a Predictor of Unexpected Re-Admission and Mortality after Intensive Care Unit Discharge

Predicting unexpected intensive care unit (ICU) re-admission and mortality after critical illness is difficult. This study assessed the associations between eosinopenia on the day of ICU discharge and outcomes after critical illness. This retrospective cohort study involved a total of 1446 critically ill patients who survived their first ICU admission between January 2009 and March 2010 in a multidisciplinary ICU in Western Australia. Eosinopenia was defined as eosinophil count <0.01×109/l and the date of censor for survival was 31 October 2011. Of the 1446 patients included in the study, 106 patients (7.3%) were re-admitted to the ICU during the same hospitalisation and 178 patients died (12.3%) after ICU discharge. Eosinopenia at ICU discharge occurred in 130 patients (9.7%) and was more common among those who were subsequently re-admitted (18.6 vs 8.6%) or died after ICU discharge (22.5 vs 7.5%). Eosinopenia remained associated with ICU re-admission (odds ratio 2.50, 95% confidence interval 1.38-4.50; P=0.002) and post-ICU mortality (hazard ratio 2.65, 95% confidence interval 1.77-3.98; P=0.001) after adjusting for age, gender, nocturnal discharge, neutrophil count at ICU discharge, elective surgical admission, Sequential Organ Failure Assessment scores, Acute Physiology and Chronic Health Evaluation II predicted mortality and chronic medical diseases. Eosinopenia at ICU discharge explained about 8.4% of the variability and was the third most important factor in explaining the variability in survival after ICU discharge. In summary, eosinopenia at ICU discharge was associated with an increased risk of unexpected ICU re-admission and post-ICU mortality.

C-Reactive Protein as a Predictor of Outcome After Discharge From the Intensive Care

Abstract Background Recent studies have found plasma C-reactive protein (CRP) to be a predictor of outcome after discharge from the intensive care unit (ICU). To assess the generalizability of this finding, we assessed the value of CRP on the day of ICU discharge as a predictor of unplanned ICU readmission and unexpected death within 2 weeks. Plasma albumin and white cell count at discharge were also considered as markers associated with ongoing inflammation. Methods This was a single-centre observational study involving a medical–surgical ICU in a university teaching hospital. Data were prospectively collected from 1487 admissions involving 1401 patients over a 12 month period. Patients' admission details and APACHE II score were collected in addition to plasma CRP, white cell count, and albumin values from the day of discharge from ICU. We assessed the difference in these variables between patients who were readmitted, who died unexpectedly, and those who did not. Results We found that 9.9% of patients discharged were either readmitted (7.0%) or died unexpectedly (2.9%). Patients who were readmitted had a lower plasma albumin concentration [20 (16, 24) vs 22 (19, 27), P vs 15 (12, 18), P =0.02]. Patients who died unexpectedly on the ward were older [mean (sd): 76 (12) vs 59 (19), P vs 15 (12, 18), P Conclusions In a mixed medical–surgical intensive care, plasma CRP measured at the day of discharge from intensive care is not a predictor of readmissions or deaths.

Computerized prediction of intensive care unit discharge after cardiac surgery: development and validation of a Gaussian processes model

BackgroundThe intensive care unit (ICU) length of stay (LOS) of patients undergoing cardiac surgery may vary considerably, and is often difficult to predict within the first hours after admission. The early clinical evolution of a cardiac surgery patient might be predictive for his LOS. The purpose of the present study was to develop a predictive model for ICU discharge after non-emergency cardiac surgery, by analyzing the first 4 hours of data in the computerized medical record of these patients with Gaussian processes (GP), a machine learning technique.MethodsNon-interventional study. Predictive modeling, separate development (n = 461) and validation (n = 499) cohort. GP models were developed to predict the probability of ICU discharge the day after surgery (classification task), and to predict the day of ICU discharge as a discrete variable (regression task). GP predictions were compared with predictions by EuroSCORE, nurses and physicians. The classification task was evaluated using aROC for discrimination, and Brier Score, Brier Score Scaled, and Hosmer-Lemeshow test for calibration. The regression task was evaluated by comparing median actual and predicted discharge, loss penalty function (LPF) ((actual-predicted)/actual) and calculating root mean squared relative errors (RMSRE).ResultsMedian (P25-P75) ICU length of stay was 3 (2-5) days. For classification, the GP model showed an aROC of 0.758 which was significantly higher than the predictions by nurses, but not better than EuroSCORE and physicians. The GP had the best calibration, with a Brier Score of 0.179 and Hosmer-Lemeshow p-value of 0.382. For regression, GP had the highest proportion of patients with a correctly predicted day of discharge (40%), which was significantly better than the EuroSCORE (p < 0.001) and nurses (p = 0.044) but equivalent to physicians. GP had the lowest RMSRE (0.408) of all predictive models.ConclusionsA GP model that uses PDMS data of the first 4 hours after admission in the ICU of scheduled adult cardiac surgery patients was able to predict discharge from the ICU as a classification as well as a regression task. The GP model demonstrated a significantly better discriminative power than the EuroSCORE and the ICU nurses, and at least as good as predictions done by ICU physicians. The GP model was the only well calibrated model.

Should C-reactive protein concentration at ICU discharge be used as a prognostic marker?

BackgroundAbout one third of hospital mortality in critically ill patients occurs after Intensive Care Unit (ICU) discharge. Some authors have recently hypothesized that unresolved or latent inflammation and sepsis may be an important factor that contributes to death following successful discharge from the ICU.AimThe aim of our study was to determine the ability of the clinical and inflammatory markers at ICU discharge to predict post-ICU mortality.MethodsA prospective observational cohort study was conducted during a 14-month period in an 8 bed polyvalent ICU. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA) score, Therapeutic Intervention Scoring System-28 (TISS-28), C-reactive protein (CRP), white cell count (WCC) and body temperature of the day of ICU discharge were collected from patients who survived their first ICU admission.ResultsDuring this period 156 patients were discharged alive from the ICU. A total of 29 patients (18.6%) died after ICU discharge. There were no differences in clinical and demographic characteristics between survivors and nonsurvivors. C-reactive protein levels at ICU discharge were not significantly different between survivors and nonsurvivors. The area under receiver operating characteristics curves of APACHE II, SAPS II, SOFA, TISS-28, CRP, WCC and body temperature at ICU discharge as prognostic markers of hospital death were 0.76 (95% confidence interval (CI) 0.67-0.86); 0.75 (95% CI 0.66-0.85); 0.72 (95% CI 0.62-0.83); 0.64 (95% CI 0.52-0.77); 0.55 (95% CI 0.43-0.67); 0.55 (95% CI 0.42-0.66) and 0.54 (95% CI 0.44-0.67) respectively. The hospital mortality rate of the patients with CRP <5, 5-10, >10 mg/dL was 15.1%, 16.1% and 33.3% respectively (p = NS).ConclusionsAt ICU discharge serum CRP concentration was a poor marker of post-ICU prognosis. Post-ICU death appears to be unrelated to the persistent inflammatory response.

C-reactive protein as a predictor of outcome after discharge from the intensive care: a prospective observational study

BackgroundRecent studies have found plasma C-reactive protein (CRP) to be a predictor of outcome after discharge from the intensive care unit (ICU). To assess the generalizability of this finding, we assessed the value of CRP on the day of ICU discharge as a predictor of unplanned ICU readmission and unexpected death within 2 weeks. Plasma albumin and white cell count at discharge were also considered as markers associated with ongoing inflammation. MethodsThis was a single-centre observational study involving a medical–surgical ICU in a university teaching hospital. Data were prospectively collected from 1487 admissions involving 1401 patients over a 12 month period. Patients’ admission details and APACHE II score were collected in addition to plasma CRP, white cell count, and albumin values from the day of discharge from ICU. We assessed the difference in these variables between patients who were readmitted, who died unexpectedly, and those who did not. ResultsWe found that 9.9% of patients discharged were either readmitted (7.0%) or died unexpectedly (2.9%). Patients who were readmitted had a lower plasma albumin concentration [20 (16, 24) vs 22 (19, 27), P<0.001] and a higher admission APACHE II score [median (inter-quartile range, IQR) 16.5 (13, 21) vs 15 (12, 18), P=0.02]. Patients who died unexpectedly on the ward were older [mean (sd): 76 (12) vs 59 (19), P<0.001] and had a higher APACHE II score [21 (17.25, 26) vs 15 (12, 18), P<0.001]. There was not a statistically significant difference in CRP concentration between patients who either required ICU readmissions or died unexpectedly on the ward and those who did not. ConclusionsIn a mixed medical–surgical intensive care, plasma CRP measured at the day of discharge from intensive care is not a predictor of readmissions or deaths.

Development and validation of a questionnaire for quantitative assessment of perceived discomforts in critically ill patients

To develop and validate the IPREA (Inconforts des Patients de REAnimation) questionnaire for the assessment of discomfort perceived by patients related to their intensive care unit (ICU) stay. This was a two step-study comprising a phase of item generation conducted in one ICU and a phase of psychometric evaluation during a multicenter prospective cohort study in 14 ICUs. Patients were unselected consecutive adult surviving ICU patients. On the day of ICU discharge, a nurse asked patients to rate the severity of 16 discomfort sources, from 0 to 100. Ten percent of patients were randomly chosen to be questioned again to assess the reproducibility. Of 1,380 eligible patients, 1,113 survived and 868 patients could be questioned. The highest scores were for sleep deprivation (35 ± 33), being restrained by tubing, wires, and cables (33 ± 30), pain (32 ± 30), and thirst (32 ± 34). No multidimensional structure was identified. The mean overall score of discomfort was 22 ± 14. Internal consistency was satisfactory using Cronbach's alpha coefficient (0.78). The test-retest reliability study found average measure intraclass correlations ranging from 0.70 to 0.92. The mean duration of the questionnaire administration was 10 ± 7 min. The psychometric properties and acceptability of the IPREA questionnaire make it a potential instrument for measuring discomfort perceived by unselected ICU patients.

Bayesian Approach to Predict Hospital Mortality of Intensive Care Readmissions during the Same Hospitalisation

No specific prognostic model has been developed for patients readmitted to the intensive care unit (ICU) during the same hospitalisation. This study assesses the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II predicted mortality measured at the time of ICU readmission and whether incorporating information prior to the readmission will improve its performance to predict hospital mortality of patients readmitted to ICU during the same hospitalisation. A total of 602 readmissions during the same hospitalisation between 1987 and 2002 were identified. The first admission APACHE II predicted mortality was significantly associated with the hospital mortality only in the subgroup of patients readmitted within seven days of ICU discharge (odds ratio 1.16, 95% confidence interval 1.01 to 1.34; P = 0.035). In the subgroups of patients readmitted within seven days of discharge, the readmission APACHE II predicted mortality was also significantly better than the first admission APACHE II predicted mortality in discriminating between survivors and non-survivors (area under the receiver operating characteristic curve: 0.785 vs. 0.676, z statistic = 2.93; P = 0.003). Incorporating the first admission APACHE II predicted mortality to the readmission APACHE II predicted mortality, either by multilevel likelihood ratios or logistic regression, did not significantly improve its discrimination (area under the receiver operating characteristic curve: 0.792 vs. 0.785, z statistic = 0.52; P = 0.603). Our results suggested that information on prior ICU admission during the same hospitalisation is not as important as the severity of illness measured at the time of readmission in determining the mortality of intensive care readmissions during the same hospitalisation.