Day Of Intensive Care Unit Admission Research Articles

Predictive value of six critical illness scores for 28-day death risk in comprehensive and specialized intensive care unit patients based on MIMIC-IV database

To explore the basic characteristics of various types of intensive care unit (ICU) patients and the predictive value of six common disease severity scores in critically ill patients on the first day on the 28-day death risk. The general information, disease severity scores [acute physiology score III (APS III), Oxford acute disease severity (OASIS) score, Logistic organ dysfunction score (LODS), simplified acute physiology score II (SAPS II), systemic inflammatory response syndrome (SIRS) score and sequential organ failure assessment (SOFA) score], prognosis and other indicators of critically ill patients admitted from 2008 to 2019 were extracted from Medical Information Mart for Intensive Care-IV 2.0 (MIMIC-IV 2.0). The receiver operator characteristic curve (ROC curve) of six critical illness scores for 28-day death risk of patients in various ICU, and the area under the ROC curve (AUC) was calculated, the optimal Youden index was used to determine the cut-off value, and the AUC of various ICU was verified by Delong method. A total of 53 150 critically ill patients were enrolled, with medical ICU (MICU) accounted for the most (19.25%, n = 10 233), followed by cardiac vascular ICU (CVICU) with 17.78%(n = 9 450), and neurological ICU (NICU) accounted for the least (6.25%, n = 3 320). The patients in coronary care unit (CCU) were the oldest [years old: 71.79 (60.27, 82.33)]. The length of ICU stay in NICU was the longest [days: 2.84 (1.51, 5.49)] and accounted for the highest proportion of total length of hospital stay [63.51% (34.61%, 97.07%)]. The patients in comprehensive ICU had the shortest length of ICU stay [days: 1.75 (0.99, 3.05)]. The patients in CVICU had the lowest proportion of length of ICU stay to total length of hospital stay [27.69% (18.68%, 45.18%)]. The six scores within the first day of ICU admission in NICU patients were lower than those in the other ICU, while APS III, LODS, OASIS, and SOFA scores in MICU patients were higher than those in the other ICU. SAP II and SIRS scores were both the highest in CVICU, respectively. In terms of prognosis, MICU patients had the highest 28-day mortality (14.14%, 1 447/10 233), while CVICU patients had the lowest (2.88%, 272/9 450). ROC curve analysis of the predictive value of each score on the 28-day death risk of various ICU patients showed that, the predictive value of APS III, LODS, and SAPS II in comprehensive ICU were higher [AUC and 95% confidence interval (95%CI) were 0.84 (0.83-0.85), 0.82 (0.81-0.84), and 0.83 (0.82-0.84), respectively]. The predictive value of OASIS, LODS, and SAPS II in surgical ICU (SICU) were higher [AUC and 95%CI were 0.80 (0.79-0.82), 0.79 (0.78-0.81), and 0.79 (0.77-0.80), respectively]. The predictive value of APS III and SAPS II in MICU were higher [AUC and 95%CI were 0.84 (0.82-0.85) and 0.82 (0.81-0.83), respectively]. The predictive value of APS III and SAPS II in CCU were higher [AUC and 95%CI were 0.86 (0.85-0.88) and 0.85 (0.83-0.86), respectively]. The predictive value of LODS and SAPS II in trauma ICU (TICU) were higher [AUC and 95%CI were 0.83 (0.82-0.83) and 0.83 (0.82-0.84), respectively]. The predictive value of OASIS and SAPS II in NICU were higher [AUC and 95%CI were 0.83 (0.80-0.85) and 0.81 (0.78-0.83), respectively]. The predictive value of APS III, LODS, and SAPS II in CVICU were higher [AUC and 95%CI were 0.84 (0.83-0.85), 0.81 (0.80-0.82), and 0.78 (0.77-0.78), respectively]. For the patients in comprehensive ICU, MICU, CCU, and CVICU, APS III or SAPS II can be applied for predicting 28-day death risk. For the patients in SICU and NICU, OASIS or SAPS II can be applied to predict 28-day death risk. For the patients in TICU, SAPS II or LODS can be applied for predicting 28-day death risk. For CVICU patients, APS III or LODS can be applied to predict 28-day death risk.

Nutrition Characteristics and Delivery in Relation to 28-day Mortality in Critically Ill Patients

Introduction: The limited data regarding nutrition characteristics and the delivery of critically ill patients in South Asia is intriguing. This study was conducted to investigate the nutrition characteristics and delivery in relation to 28-day mortality in mechanically ventilated patients. Methods: This prospective observational study was conducted in the intensive care unit (ICU) of the Maldives government referral hospital. Data about nutrition characteristics and delivery were collected from the ICU charts, and each patient was followed for a maximum of 28 days. Results: We recruited a total of 115 patients (mean age: 61.57±17.26 years, 52% females, mean BMI: 25.5±6.19kg/m2), of which 61 (53%) of them died within 28 days of ICU admission. Mean energy intake was 681.15±395.37 kcal per day, and mean protein intake was 30.32±18.97g per day. In the univariate logistic regression analysis, length of stay in ICU (OR = 0.950, 95% CI: 0.908 – 0.994, p = 0.027), and received intervention by a dietitian (OR = 0.250, 95% CI: 0.066 – 0.940, p = 0.040) were associated with 28-day mortality. None of the factors in the multivariate regression analysis remains significant when adjusted for sex, SOFA total score, daily energy and protein dosage. Conclusion: 28-day mortality was much higher in this study than in similar studies in South Asia, Asia and around the globe. None of the variables was significantly associated with 28-day mortality in the multivariate logistic model. However, there was a trend towards higher mortality for patients with shorter length of stay in the ICU, larger mean gastric residual volume, and no intervention by a dietitian.

Cell-Free DNA as Biomarker for Sepsis by Integration of Microbial and Host Information.

Cell-free DNA (cfDNA) is emerging as a biomarker for sepsis. Previous studies have been focused mainly on identifying blood infections or simply quantifying cfDNA. We propose that by characterizing multifaceted unexplored components, cfDNA could be more informative for assessing this complex syndrome. We explored multiple aspects of cfDNA in septic and nonseptic intensive care unit (ICU) patients by metagenomic sequencing, with longitudinal measurement and integrative assessment of plasma cfDNA quantity, human cfDNA fragmentation patterns, infecting pathogens, and overall microbial composition. Septic patients had significantly increased cfDNA quantity and altered human cfDNA fragmentation pattern. Moreover, human cfDNA fragments appeared to comprise information about cellular oxidative stress and could indicate disease severity. Metagenomic sequencing was more sensitive than blood culture in detecting bacterial infections and allowed for simultaneous detection of viral pathogens. We found differences in microbial composition between septic and nonseptic patients and between survivors and nonsurvivors by 28-day mortality, both on the first day of ICU admission and across the study period. By integrating all the information into a machine learning model, we achieved improved performance in identifying sepsis and prediction of clinical outcome for ICU patients with areas under the curve of 0.992 (95% CI 0.969-1.000) and 0.802 (95% CI 0.605-0.999), respectively. We were able to diagnose sepsis and predict mortality as soon as the first day of ICU admission by integrating multifaceted cfDNA information obtained in a single metagenomic assay; this approach could provide important advantages for clinical management and for improving outcomes in ICU patients.

Development and Validation of Simplified Delirium Prediction Model in Intensive Care Unit.

BackgroundThe intensive care unit (ICU) is where various medical staffs and patients with diverse diseases convene. Regardless of complexity, a delirium prediction model that can be applied conveniently would help manage delirium in the ICU.ObjectiveThis study aimed to develop and validate a generally applicable delirium prediction model in the ICU based on simple information.MethodsA retrospective study was conducted at a single hospital. The outcome variable was defined as the occurrence of delirium within 30 days of ICU admission, and the predictors consisted of a 12 simple variables. Two models were developed through logistic regression (LR) and random forest (RF). A model with higher discriminative power based on the area under the receiver operating characteristics curve (AUROC) was selected as the final model in the validation process.ResultsThe model was developed using 2,588 observations (training dataset) and validated temporally with 1,109 observations (test dataset) of ICU patients. The top three influential predictors of the LR and RF models were the restraint, hospitalization through emergency room, and drainage tube. The AUROC of the LR model was 0.820 (CI 0.801–0.840) and 0.779 (CI 0.748–0.811) in the training and test datasets, respectively, and that of the RF model was 0.762 (CI 0.732–0.792) and 0.698 (0.659–0.738), respectively. The LR model showed better discriminative power (z = 4.826; P < 0.001).ConclusionThe LR model developed with brief variables showed good performance. This simplified prediction model will help screening become more accessible.

Incidence of acute myocardial injury and its association with left and right ventricular systolic dysfunction in critically ill COVID-19 patients

BackgroundPrevious studies have found an increase in cardiac troponins (cTns) and echocardiographic abnormalities in patients with COVID-19 and reported their association with poor clinical outcomes. Whether acute injury occurs during the course of critical care and if it is associated with cardiac function is unknown.The purpose of this study was to document the incidence of acute myocardial injury (AMInj) and echocardiographically defined left ventricular (LV) and right ventricular (RV) systolic dysfunction in consecutive patients admitted to an intensive care unit (ICU) for COVID-19. The relationship between AMInj and echocardiographic abnormalities during the first 14 days of ICU admission was studied. Finally, the association between echocardiographic findings, AMInj and clinical outcome was evaluated.MethodsSeventy-four consecutive patients (≥18 years) admitted to the ICU at Linköping University Hospital between 19 Mar 2020 and 31 Dec 2020 for COVID-19 were included. High-sensitivity troponin-T (hsTnT) was measured daily for up to 14 days. Transthoracic echocardiography was conducted within 72 h of ICU admission. Acute myocardial injury was defined as an increased hsTnT > 14ng/l and a > 20% absolute change with or without ischaemic symptoms. LV and RV systolic dysfunction was defined as at least 2 abnormal indicators of systolic function specified by consensus guidelines.ResultsIncreased hsTnT was observed in 59% of patients at ICU admission, and 82% developed AMInj with peak levels at 8 (3–13) days after ICU admission. AMInj was not statistically significantly associated with 30-day mortality but was associated with an increased duration of invasive mechanical ventilation (10 (3–13) vs. 5 days (0–9), p=0.001) as well as ICU length of stay (LOS) (19.5 (11–28) vs. 7 days (5–13), p=0.015). After adjustment for SAPS-3 and admission SOFA score, the effect of AMInj was significant only for the duration of mechanical ventilation (p=0.030).The incidence of LV and RV dysfunction was 28% and 22%, respectively. Only indices of LV and RV longitudinal contractility (mitral and tricuspid annular plane systolic excursion) were associated with AMInj. Echocardiographic parameters were not associated with clinical outcome.ConclusionsMyocardial injury is common in critically ill patients with COVID-19, with AMInj developing in more than 80% after ICU admission. In contrast, LV and RV dysfunction occurred in approximately one-quarter of patients. AMInj was associated with an increased need for mechanical ventilation and ICU LOS but neither AMInj nor ventricular dysfunction was significantly associated with mortality.

Early Renal-Replacement Therapy May Reduce the All-Cause Mortality of Severe COVID-19: An Observational Cohort Study

Introduction: The efficacy of renal-replacement treatment (RRT) remains to be validated in COVID-19. In this retrospective cohort study, we aimed to assess the efficacy of early initiation of RRT in intensive care unit (ICU) adults with severe COVID-19. Methods: Fifty-eight adult patients in ICU with critically ill or severe COVID-19 with a tendency of critical illness were recruited from February 9, 2020, to March 30, 2020. Early RRT were determined by the ICU medical team based on boom in cytokines levels, increased organs injury/failure, and rapid aggravation of condition. All participants were followed up from the first day of ICU admission to March 30, 2020. The primary outcome was all-cause mortality in ICU. Results: The mean age of the cohort was 68.4 ± 14.6 years, with 81.0% having at least one comorbidity before hospitalization. Twenty patients (34.5%) initiated early RRT after 24.1 ± 10.4 days from the onset and 6.4 ± 3.6 days from ICU admission. Thirty-four of 58 participants (58.6%) died during ICU follow-up. Univariate and multivariate Cox proportional-hazards model showed that early RRT was associated with a lower risk of all-cause mortality in ICU with an adjusted HR of 0.280 (95% CI: 0.106–0.738, p = 0.010). Sudden unexpected death (SUD) was remarkably reduced in the early RRT group, compared with the control group (0.2 vs. 2.9 per 100 person-day, p = 0.02). Conclusion: Early RRT can reduce the all-cause in-hospital mortality, especially SUD in patients with severe COVID-19, but not improve multi-organ impairment or increase the risk of AKI. Early initiation of RRT merits an optional strategy in critically ill patients with COVID-19 (ChiCTR2000030773).

Development and validation of early prediction models for new-onset functional impairment at hospital discharge of ICU admission.

We aimed to develop and validate models for predicting new-onset functional impairment after intensive care unit (ICU) admission with predictors routinely collected within 2days of admission. In this multi-center retrospective cohort study of acute care hospitals in Japan, we identified adult patients who were admitted to the ICU with independent activities of daily living before hospitalization and survived for at least 2days from April 2014 to October 2020. The primary outcome was functional impairment defined as Barthel Index ≤ 60 at hospital discharge. In the internal validation dataset (April 2014 to March 2019), using routinely collected 94 candidate predictors within 2 days of ICU admission, we trained and tuned the six conventional and machine-learning models with repeated random sub-sampling cross-validation. We computed the variable importance of each predictor to the models. In the temporal validation dataset (April 2019 to October 2020), we measured the performance of these models. We identified 19,846 eligible patients. Functional impairment at discharge was developed in 33% of patients (n = 6488/19,846). In the temporal validation dataset, all six models showed good discrimination ability with areas under the curve above 0.86, and the differences among the six models were negligible. Variable importance revealed newly detected early predictors, including worsened neurologic conditions and catabolism biomarkers such as decreased serum albumin and increased blood urea nitrogen. We successfully developed early prediction models of new-onset functional impairment after ICU admission that achieved high performance using only data routinely collected within 2days of ICU admission.

Physical Function in Critically Ill Patients during the Duration of ICU and Hospital Admission.

BackgroundImpaired physical activity and functional ability is a significant problem in critical illness survivors. Measurement of physical functioning through intensive care unit (ICU) stay determines patients at risk of poor physical outcomes, monitors efficacy of intervention, and informs recovery trajectories.ObjectivesStudy objective was to assess physical function trajectory and identify residual functional limitations in critically ill patients admitted to ICU at the point of discharge from the hospital using robust clinical measures.Materials and methodsFollowing ethical approval, 100 patients (78 males and 22 females) admitted to medical and surgical ICUs were recruited. Scores on Functional Status Score in ICU (FSS-ICU), Physical Function ICU Test (PFIT), and Functional Independence Measure (FIM) were recorded. Day of physiotherapy reference in the ICU was considered as day of ICU admission. Data were collected at three points, namely ICU admission, ICU discharge, and hospital discharge.ResultsScores on all outcome measures increased linearly, and an upward functional trajectory was observed in patients from the point of ICU admission till hospital discharge (p >0.001).ConclusionDeficits in functional recovery exist until hospital discharge, substantiating the need to implement home-based rehabilitation to recover optimum physical function and independence in activities of daily living.How to cite this articleAglawe DR, Agarwal BM, Sawant BD. Physical Function in Critically Ill Patients during the Duration of ICU and Hospital Admission. Indian J Crit Care Med 2022;26(3):314–318.

Clinical characteristics of Gram-negative and Gram-positive bacterial infection in acute cholangitis: a retrospective observational study

BackgroundTo investigate the difference in the severity of illness, organ dysfunction, and prognosis of acute cholangitis due to different pathogenic bacterial infection types.MethodsA retrospective observational study was performed. Patients who met the selection criteria according to blood culture and bile culture results of different pathogenic bacterial were divided into groups. The severity of illness, organ dysfunction, and prognosis of the groups were analyzed and compared comprehensively.ResultsA total of 424 patients were included, and no bacterial growth developed in 111 patients (26.2%). Among the 313 patients (73.8%) with bacterial growth, 155 patients had only Gram-negative bacteria cultured (49.5%), 48 patients had only Gram-positive bacteria cultured (15.3%), and 110 patients had both Gram-negative and Gram-positive bacteria cultured (35.1%). The proportion of Grade III patients and the APACHE II and SOFA scores of the mixed Gram-negative and positive group were the highest (p < 0.05); the intensive care unit admission day and hospital stay were longer, and the mortality rate were also higher 20/110 (18.2%) than the other two groups. Regression analysis showed that bacterial growth was an independent risk factor for organ dysfunction. The risks of an increased septic shock, neurological dysfunction, hepatic dysfunction, hematological dysfunction, and respiratory dysfunction in the mixed Gram-negative and positive group were higher than the Gram-negative group (P < 0.05). The Cox proportional hazards regression prompt showed that different culture results were independent risk factors for death. The mixed Gram-negative and positive group had increased hazard ratios and 95% CI of 7.30 (95% CI 1.55 to 34.38) compared with the Gram-negative group. There was no difference between the Gram-negative group and the Gram-positive group in the severity of illness, organ dysfunction, intensive care unit admission day, hospital stay, mortality rate, and risk of death (P > 0.05).ConclusionsIn acute cholangitis, mixed infection with Gram-negative and Gram-positive bacteria was more severe and was associated with a higher risk of death. There were no apparent differences between Gram-negative and Gram-positive bacterial infections.

The COMPASS-COVID-19-ICU Study: Identification of Factors to Predict the Risk of Intubation and Mortality in Patients with Severe COVID-19

In some patients, SARS-CoV-2 infection induces cytokine storm, hypercoagulability and endothelial cell activation leading to worsening of COVID-19, intubation and death. Prompt identification of patients at risk of intubation is an urgent need. Objectives. To derive a prognostic score for the risk of intubation or death in patients with COVID-19 admitted in intensive care unit (ICU), by assessing biomarkers of hypercoagulability, endothelial cell activation and inflammation and a large panel of clinical analytes. Design, Setting and Participants. A prospective, observational study enrolled 118 patients with COVID-19 admitted in the ICU. On the first day of ICU admission, all patients were assessed for biomarkers (protein C, protein S, antithrombin, D-Dimer, fibrin monomers, FVIIa, FV, FXII, FXII, FVIII, FvW antigen, fibrinogen, procoagulant phospholipid dependent clotting time, TFPI, thrombomodulin, P-selectin, heparinase, microparticles exposing TF, IL-6, complement C3a, C5a, thrombin generation, PT, aPTT, hemogram, platelet count) and clinical predictors. Main Outcomes and Measures. The clinical outcomes were intubation and mortality during hospitalization in ICU. Results: The intubation and mortality rates were 70% and 18%, respectively. The COMPASS-COVID-19-ICU score composed of P-Selectin, D-Dimer, free TFPI, TF activity, IL-6 and FXII, age and duration of hospitalization predicted the risk of intubation or death with high sensitivity and specificity (0.90 and 0.92, respectively). Conclusions and Relevance. COVID-19 is related to severe endothelial cell activation and hypercoagulability orchestrated in the context of inflammation. The COMPASS-COVID-19-ICU risk assessment model is accurate for the evaluation of the risk of mechanical ventilation and death in patients with critical COVID-19. The COMPASS-COVID-19-ICU score is feasible in tertiary hospitals and could be placed in the diagnostic procedure of personalized medical management and prompt therapeutic intervention.

Mortality Among COVID-19 Patients in the Intensive Care Unit (ICU): A Single-Centre Study from a Malaysian Perspective

PurposeThis study investigated the prevalence of mortality among COVID-19 patients admitted to an intensive care unit (ICU) at a single centre hospital in Klang Valley, Selangor, Malaysia. Besides, adverse clinical events (ACE) among COVID-19 patients admitted to ICU who died and were alive were compared, and the factors associated with mortality were explored.Methods & MaterialsPatients admitted to a single centre ICU with polymerase chain reaction (PCR) confirmed of SARS-CoV-2 virus within February 2020-2021 were included in this study. Adverse clinical event (ACE) consists of the presence of pulmonary embolism (PE), deep vein thrombosis (DVT), line-related thrombosis, stroke, myocardial infarction (MI) and peripheral artery disease (PAD) during their ICU admission. A composite of ACE comprised ≥ 1 PE, DVT, line-related thrombosis, stroke, MI and PAD. Mortality is defined as COVID-19 patients who died during ICU admission throughout data collection.ResultsMean (SD) age was 56.6 (13.7) with 63.5% male and 61.6% Malay. Median (IQR) 7 (3-14) days of ICU admission, 64.2%, 53.2 % and 20.9% had underlying hypertension, diabetes, and obesity, respectively. Out of 534 patients included in the study, 122 patients died, with 64.8% developed ≥ 1 ACE compared to 39.1% patients who survived the infection. Higher proportion of deceased patients developed PE (47.5% vs. 34%; p=0.006), MI (16.4% vs. 4.6%; p<0.001), stroke (12.3% vs. 1.5%; p<0.001) and DVT (2.5% vs. 0.2%; p=0.04) than those who survived. Significant predictors of mortality on multivariate logistic regression model include age [OR 1.05 (95% CI 1.03 – 1.07)], length of ICU stay [OR 1.05 (1.02 – 1.07), chronic kidney disease [OR 2.30 (1.32 – 4.01), and presence of ≥ 1 ACE [OR 2.32 (1.45 – 3.72)].ConclusionThe overall mortality of COVID-19 patients admitted to a single centre ICU is high (22.8%), with greater proportion of patients who developed ≥1 ACE. Key factors associated with the mortality were age, length of ICU stays, underlying chronic kidney disease and presence of ≥ 1 ACE. This finding might be helpful to the healthcare providers in the early detection and prevention of ACE associated with mortality among COVID-19 patients admitted to the ICU.

Characteristics and clinical outcomes of COVID-19 patients with pulmonary disorders: A single-center, retrospective observational study.

IntroductionMortality rates and clinical characteristics of patients with coronavirus disease 2019 (COVID‐19) admitted to the intensive care unit (ICU) vary significantly.ObjectivesTo describe the data of patients with pulmonary comorbidities who were admitted to the ICU with COVID‐19 in Qatar in terms of demographic characteristics, coexisting conditions, imaging findings, and outcomes.MethodsWe conducted a retrospective study of the outcomes with regard to mortality and requirement of invasive ventilation, demographic characteristics, coexisting conditions, secondary infections, and imaging findings for critical care patients with COVID‐19 in Qatar who had pulmonary comorbidities between March and June 2020.ResultsA total of 923 patients were included, 29 (3.14%) were found to have pulmonary disease. All these 29 patients' respiratory disease was noted to be asthma. Among these, three patients (10.3%) died in the ICU within 28 days of ICU admission. They were all above 50 years old. Nineteen (66%) patients required intubation and mechanical ventilation. Twenty‐one (72.4%) patients were males. The most common comorbidities included diabetes mellitus (55.1%) and hypertension (62%). Eighteen (62%) patients developed secondary infections in the ICU. Five (17.24%) patients developed renal impairment. Twenty (69%) patients received tocilizumab as part of their COVID‐19 management, and out of these 16 (80%) patients developed a coinfection.ConclusionPatients with pulmonary disorders had higher mortality rates than other patients admitted to ICU during the same time frame with similar comorbidities; these patients require extra consideration and care to avoid disease progression and death.

Usefulness of Selected Peripheral Blood Counts in Predicting Death in Patients with Severe and Critical COVID-19.

Background. Immune dysregulation and hypoxemia are two important pathophysiological problems in patients with COVID-19 that affect peripheral blood count parameters. We hypothesized that assessment of the neutrophil–lymphocyte ratio (NLR) and red blood cell distribution width index (RDW-SD) could predict death in patients with severe and critical COVID-19. Methods. Seventy patients admitted to the intensive care unit (ICU) for COVID-19 acute respiratory failure were included in the study. RDW-SD and NLR on the day of ICU admission and peak values during the entire hospitalization were assessed. The primary endpoint was death before ICU discharge. Results. Patients who died had higher NLR on admission (20.3, IQR 15.3–30.2 vs. 11.0, IQR 6.8–16.9; p = 0.003) and higher RDW-SD (48.1 fL; IQR 43.1–50.5 vs. 43.9 fL; IQR 40.9–47.3, p = 0.01) than patients discharged from the ICU. NLR and RDW-SD values on ICU admission accurately predicted death in 76% (AUC = 0.76; 95%CI 0.65–0.86; p = 0.001; cut-off > 14.38) and 72% of cases (AUC = 0.72; 95%CI 0.60–0.82; p = 0.003; cut-off > 44.7 fL), respectively. Multivariable analysis confirmed that NLR > 14.38 on the day of ICU admission was associated with a 12-fold increased risk of death (logOR 12.43; 95%CI 1.61–96.29, p = 0.02), independent of other blood counts, clinical and demographic parameters. Conclusions. Neutrophil–lymphocyte ratio determined on the day of ICU admission may be a useful biomarker predicting death in patients with severe and critical COVID-19.

Predictive ability of the sequential organ failure assessment score for in-hospital mortality in patients with cardiac critical illnesses: a nationwide observational study.

Several studies have reported a high predictive ability of the Sequential Organ Failure Assessment (SOFA) score for in-hospital mortality specifically for patients with cardiac critical illnesses, however, differences according to the admission classification (surgical or non-surgical) are unknown. The present study aimed to evaluate the predictive ability of the SOFA score in surgical and non-surgical patients with cardiac critical illnesses. Using the Japanese nationwide Diagnosis Procedure Combination database, we identified patients with cardiac critical illnesses, defined as patients admitted to the intensive care unit (ICU) and treated by cardiologists or cardiovascular surgeons as their physicians in charge from April 2018 to March 2020. The discriminatory ability of the SOFA score for in-hospital mortality was assessed by calculating the area under the receiver operating characteristic curve (AUROC). Among 52 819 eligible patients with available data on their SOFA scores, 33 526 (64%) were postoperative cardiac surgeries. The median SOFA score on ICU admission was 5.0 (interquartile range, 2.0-8.0) and overall in-hospital mortality 6.8%. The AUROC of the SOFA score was 0.75 [95% confidence interval (CI), 0.75-0.76]. In the subgroup analyses, the AUROCs were 0.76 (95% CI, 0.74-0.77) in the surgical patients, 0.83 (95% CI, 0.83-0.84) in the non-surgical patients, and 0.88 (95% CI, 0.87-0.89) in the non-surgical acute coronary syndrome patients. The predictive ability of the SOFA score on the day of ICU admission for in-hospital mortality was confirmed to be acceptable in the patients with cardiac critical illnesses and varied according to the admission classification and primary diagnoses.

Candidemia Among Coronavirus Disease 2019 Patients in Turkey Admitted to Intensive Care Units: A Retrospective Multicenter Study.

BackgroundWe evaluated the epidemiology of candidemia among coronavirus disease 2019 (COVID-19) patients admitted to intensive care units (ICUs).MethodsWe conducted a retrospective multicenter study in Turkey between April and December 2020.ResultsTwenty-eight of 148 enrolled patients developed candidemia, yielding an incidence of 19% and incidence rate of 14/1000 patient-days. The probability of acquiring candidemia at 10, 20, and 30 days of ICU admission was 6%, 26%, and 50%, respectively. More than 80% of patients received antibiotics, corticosteroid, and mechanical ventilation. Receipt of a carbapenem (odds ratio [OR] = 6.0, 95% confidence interval [CI] = 1.6–22.3, P = .008), central venous catheter (OR = 4.3, 95% CI = 1.3–14.2, P = .02), and bacteremia preceding candidemia (OR = 6.6, 95% CI = 2.1–20.1, P = .001) were independent risk factors for candidemia. The mortality rate did not differ between patients with and without candidemia. Age (OR = 1.05, 95% CI = 1.01–1.09, P = .02) and mechanical ventilation (OR = 61, 95% CI = 15.8–234.9, P < .0001) were independent risk factors for death. Candida albicans was the most prevalent species overall. In Izmir, Candida parapsilosis accounted for 50% (2 of 4) of candidemia. Both C parapsilosis isolates were fluconazole nonsusceptible, harbored Erg11-Y132F mutation, and were clonal based on whole-genome sequencing. The 2 infected patients resided in ICUs with ongoing outbreaks due to fluconazole-resistant C parapsilosis.ConclusionsPhysicians should be aware of the elevated risk for candidemia among patients with COVID-19 who require ICU care. Prolonged ICU exposure and ICU practices rendered to COVID-19 patients are important contributing factors to candidemia. Emphasis should be placed on (1) heightened infection control in the ICU and (2) developing antibiotic stewardship strategies to reduce irrational antimicrobial therapy.

Thromboembolic complication among COVID-19 patients in the intensive care unit (ICU): a single-centre study from a Malaysian perspective

Funding AcknowledgementsType of funding sources: None.IntroductionThe emerging complications of thromboembolism (TE) in COVID-19 patients have led to severe consequence such as death. Nonetheless, the prevalence of TE complications among COVID-19 patients in the Intensive Care Unit (ICU) in Malaysia is unknown.ObjectiveTo investigate the prevalence of thromboembolic (TE) complications including venous [deep vein thrombosis (DVT), pulmonary embolism (PE), and line related thrombosis] and arterial [stroke, peripheral arterial disease and myocardial infarction (MI)] thrombosis and mortality among COVID-19 patients admitted to an ICU at a single centre hospital. The proportions of patients with TE complication who died, and factors associated with the occurrence of thrombotic complications were explored.MethodsIn this retrospective Malaysian cohort study, patients admitted to a single centre ICU with PCR confirmed of SARS-CoV-2 virus and received adequate thromboprophylaxis within February 2020-2021 were included. Thromboembolic (TE) event is a combination of venous and arterial thrombosis.ResultsMean (SD) age 56.6 (13.7), 63.5% were male, 61.6% Malays, median (IQR) 7 (3-14) days of ICU admission, 64.2%, 53.2% and 20.9% had underlying hypertension, diabetes and obesity respectively. Of 534 patients, 4 (0.7%) developed DVT, 198 (37.1%) PE and 2 (0.4%) line related thrombosis. Meanwhile, 21 (3.9%) developed stroke, 39 (7.3%) MI, 1(0.2%) PAD and 22.8% died despite adequate thromboprophylaxis. In total, 240 (44.9%) developed TE event during their ICU admission. Significantly higher proportions of COVID-19 patients who developed complications of DVT (2.5% vs. 0.2%; p = 0.013), PE (47.5% vs 34.0%; p = 0.006), stroke (12.3% vs. 1.5; p < 0.001) and MI (16.4% vs. 4.6%; p < 0.001) died. Age, duration of ICU admission, obesity, white cell count (WCC), troponin, D-Dimer and corticosteroid use were significantly greater among those with TE events. Demographics, co-morbidities, other laboratory parameters and inflammatory markers were similar in COVID-19 patients with and without TE events. Predictors of TE events on multivariate logistic regression analysis were age [OR 1.02 (95% CI 1.00-1.03)], obesity [OR 2.84 (95% CI 1.93-4.18)], WCC [OR 1.04 (95% CI 1.00-1.07)], and duration of ICU admission [OR 1.04 (95% CI 1.02-1.06)].ConclusionIn this cohort of severely ill COVID-19 patients, the overall prevalence of TE complication was high (44.9%) with the overall mortality of 22.8% despite adequate thromboprophylaxis. Key predictors of TE events included age, obesity, white cell count, and duration of ICU admission. Perhaps a more aggressive treatment (combination of thromboprophylaxis and enhanced anti-inflammatory treatment) may be needed among COVID-19 patients admitted to ICU with high risk factors to prevent further increase in the incidence of thromboembolism and death.

Mortality and associated risk factors in patients with severe methanol or ethylene glycol poisoning treated with dialysis: a retrospective cohort study.

ObjectiveTo compare the initial clinical course and data on 90-day mortality in adults with methanol (MET) or ethylene glycol (EG) poisoning treated with dialysis.MethodsData on patient demographics and clinical parameters at intensive care unit (ICU) admission and for the first 24 hours after dialysis initiation were collected, and 90-day outcome data were collected for patients with MET (n = 15) or EG (n = 13) poisoning treated with dialysis in this retrospective cohort study.ResultsIn univariate analysis, patients with EG poisoning were older and they had lower hourly urine output during the first 24 hours after the initiation of dialysis. Six (46%) patients with MET poisoning and three (20%) patients with EG poisoning died within 90 days of ICU admission. A larger anion gap and lower pH, bicarbonate levels, base excess, and Glasgow Coma Scale scores on admission, as well as the need for mechanical ventilation, were associated with 90-day mortality.ConclusionsMetabolic acidosis, a large anion gap, and an altered mental status on admission appear to be associated with mortality in MET or EG poisoning, and EG poisoning may be linked to lower urine output.

The value of bioactive adrenomedullin and dipeptidyl peptidase 3 to predict short-term unfavourable outcomes after cardiac surgery: A prospective cohort study.

Adrenomedullin (ADM) is a key regulator of endothelial barrier function and vascular tone. Dipeptidyl peptidase 3 (DPP3) is a protease involved in the degradation of several cardiovascular mediators. Increased levels of bioactive ADM (bio-ADM) and circulating DPP3 (cDPP3) were found to predict short-term outcome in cardiogenic shock patients. To investigate the unknown temporal profiles of bio-ADM and cDPP3 and their association with short-term outcome following cardiac surgery. Prospective observational study of 203 adult cardiac surgery patients admitted to the intensive care unit (ICU) postoperatively. Plasma bio-ADM and cDPP3 levels were measured at ICU admission (day 1) and on days 2 and 3. Biomarker prediction of prolonged vasopressor dependency (>3 days), acute kidney injury (AKI) and prolonged ICU length of stay (ICU-LOS) (>3 days). bio-ADM and cDPP3 levels displayed distinct temporal profiles following cardiac surgery. cDPP3 levels were highest on day 1 and strongly correlated with surgical complexity and duration but subsequently normalised on day 2 in most patients. In contrast, bio-ADM levels on day 1 were within the normal range but subsequently increased. Day 2 bio-ADM levels were strongly associated with study outcomes: the area under the receiver-operating curves (AUROC) were 0.82 (95% CI, 0.72 to 0.92) for prolonged vasopressor dependency, 0.87 (0.81 to 0.92) for AKI and 0.82 (0.75 to 0.90) for prolonged ICU-LOS (all P < 0.0001). cDPP3 levels on day 2 also predicted these outcomes, albeit to a lesser extent, with AUROCs of 0.73 (95% CI, 0.64 to 0.81) for prolonged vasopressor dependency, 0.69 (0.61 to 0.77) for AKI and 0.70 (0.62 to 0.79) for prolonged ICU-LOS (all P < 0.0001). Following cardiac surgery, increased bio-ADM levels are strongly associated with unfavourable short-term outcomes, whereas cDPP3 levels are mainly related to surgery complexity and duration. On the basis of these findings, ADM-modulating therapies may have beneficial effects in cardiac surgery patients whereas DPP3-targeted therapies should be reserved for patient categories with higher baseline disease severity.

Joint Modeling of Repeated Measurements of Different Biomarkers Predicts Mortality in COVID-19 Patients in the Intensive Care Unit.

Introduction:Predicting disease severity is important for treatment decisions in patients with COVID-19 in the intensive care unit (ICU). Different biomarkers have been investigated in COVID-19 as predictor of mortality, including C-reactive protein (CRP), procalcitonin (PCT), interleukin-6 (IL-6), and soluble urokinase-type plasminogen activator receptor (suPAR). Using repeated measurements in a prediction model may result in a more accurate risk prediction than the use of single point measurements. The goal of this study is to investigate the predictive value of trends in repeated measurements of CRP, PCT, IL-6, and suPAR on mortality in patients admitted to the ICU with COVID-19.Methods:This was a retrospective single center cohort study. Patients were included if they tested positive for SARS-CoV-2 by PCR test and if IL-6, PCT, suPAR was measured during any of the ICU admission days. There were no exclusion criteria for this study. We used joint models to predict ICU-mortality. This analysis was done using the framework of joint models for longitudinal and survival data. The reported hazard ratios express the relative change in the risk of death resulting from a doubling or 20% increase of the biomarker’s value in a day compared to no change in the same period.Results:A total of 107 patients were included, of which 26 died during ICU admission. Adjusted for sex and age, a doubling in the next day in either levels of PCT, IL-6, and suPAR were significantly predictive of in-hospital mortality with HRs of 1.523 (1.012-6.540), 75.25 (1.116-6247), and 24.45 (1.696-1057) respectively. With a 20% increase in biomarker value in a subsequent day, the HR of PCT, IL-6, and suPAR were 1.117 (1.03-1.639), 3.116 (1.029-9.963), and 2.319 (1.149-6.243) respectively.Conclusion:Joint models for the analysis of repeated measurements of PCT, suPAR, and IL-6 are a useful method for predicting mortality in COVID-19 patients in the ICU. Patients with an increasing trend of biomarker levels in consecutive days are at increased risk for mortality.

High-dose Intravenous Vitamin C in Early Stages of Severe Acute Respiratory Syndrome Coronavirus 2 Infection: A Double-blind, Randomized, Controlled Clinical Trial.

Based on previous studies in the sepsis population, Vitamin C could prevent injuries when administered in high doses and before the damage is established. This study aimed to evaluate the protective potentials of high-dose Vitamin C in the progression of coronavirus disease 2019 (COVID-19). A double-blind, placebo-controlled clinical trial was conducted. Patients with moderate-to-severe disease severity based on the World Health Organization definition were enrolled and received 12 g/d Vitamin C (high-dose intravenous Vitamin C [HDIVC]) or placebo for 4 days. Sequential Organ Failure Assessment (SOFA) score as a primary outcome, National Early Warning Score, Ordinal Scale of Clinical Improvement, and cytokine storm biomarkers were recorded on days 0, 3, and 5. Survival was also assessed on day 28 after enrollment. Seventy-four patients (37 patients in each group) were enrolled from April 5, 2020, to November 19, 2020, and all patients completed follow-up. A lower increase in SOFA score during the first 3 days of treatment (+0.026 vs. +0.204) and a higher decrease in this parameter in the last 2 days (-0.462 vs. -0.036) were observed in the treatment group. However, these differences did not reach a significance level (P = 0.57 and 0.12, respectively). Other indices of clinical and biological improvement, length of hospitalization, and intensive care unit admission days were the same between the two groups. Treatment did not affect the 28-day mortality. Among patients with moderate-to-severe disease of COVID-19, the use of HDIVC plus standard care resulted in no significant difference in SOFA score or 28-day mortality compared to the standard care alone.