Early Intensive Care Unit Admission Research Articles

Delayed vs Early Admission to Intensive Care: A Retrospective Review of Outcomes and Clinical Indicators of Deterioration Following Trauma.

Unplanned admission to an intensive care unit (ICU) is a trauma quality improvement indicator associated with increased morbidity, mortality, and hospital resource usage. We identified demographics, injuries, and other clinical factors between early ICU admission, <72hrs after admission (EAd), and delayed admission, >72hrs (DelAd) from a medical/surgical floor. 146 trauma patients admitted to ICU at a level 1 trauma center from January 2020 to March 2023 met inclusion criteria and were divided into EAd and DelAd. No statistical differences in injury mechanism or severity were observed. Delayed admission demonstrated higher mortality (P = .001), more frequent decline in GCS (P = .045), and initiation of anticoagulation (P = .002). Abnormal EKG, orthopedic surgery during admission, and home anticoagulant and antidepressant use were statistically significant in identifying patients requiring early ICU admission.

Predicting the risk of early intensive care unit admission for patients hospitalized with acute pancreatitis using supervised machine learning

Background Acute pancreatitis (AP) is a complex and life-threatening disease. Early recognition of factors predicting morbidity and mortality is crucial. We aimed to develop and validate a pragmatic model to predict the individualized risk of early intensive care unit (ICU) admission for patients with AP. Methods The 2019 Nationwide Readmission Database was used to identify patients hospitalized with a primary diagnosis of AP without ICU admission. A matched comparison cohort of AP patients with ICU admission within 7 days of hospitalization was identified from the National Inpatient Sample after 1:N propensity score matching. The least absolute shrinkage and selection operator (LASSO) regression was used to select predictors and develop an ICU acute pancreatitis risk (IAPR) score validated by 10-fold cross-validation. Results A total of 1513 patients hospitalized for AP were included. The median age was 50.0 years (interquartile range: 39.0–63.0). The three predictors that were selected included hypoxia (area under the curve [AUC] 0.78), acute kidney injury (AUC 0.72), and cardiac arrhythmia (AUC 0.61). These variables were used to develop a nomogram that displayed excellent discrimination (AUC 0.874) (bootstrap bias-corrected 95% confidence interval 0.824–0.876). There was no evidence of miscalibration (test statistic = 2.88; P = 0.09). For high-risk patients (total score >6 points), the sensitivity was 68.94% and the specificity was 92.66%. Conclusions This supervised machine learning-based model can help recognize high-risk AP hospitalizations. Clinicians may use the IAPR score to identify patients with AP at high risk of ICU admission within the first week of hospitalization.

Course of Acute Pancreatitis Patients with Renal Failure According to Balthazar Classification.

There are criteria that include many organ systems to predict the prognosis in acute pancreatitis (AP) patients. In this study, we aimed to show how the course of the disease changes according to the Balthazar classification in AP patients presenting with renal failure. Our study included 352 patients who were admitted to the Emergency Service of our hospital and were diagnosed and hospitalized with AP. According to the Balthazar score, patients with scores of 0-2, 4-6, and 8-10 were evaluated as mild, moderate, and severe AP, respectively. Demographic data (age, gender) of all patients were documented. The etiology of AP was determined in all patients. Biliary, drug/toxic, alcohol, infections, hyperlipidemia, post-endoscopic retrograde cholangiopancreatography (ERCP), genetics, hypercalcemia, structural anomalies, and malignancy were evaluated as the etiology. Those without any underlying pathology were evaluated as idiopathic AP. The patients were divided into two groups as those with and without renal insufficiency. All patients underwent helical computed tomography (section 64, Aquilion; Toshiba Medical Systems, Tokyo) within the first 12 hours and between days 3 and 7. Pancreas, peripancreatic and extrapancreatic findings, and complications were examined. "The Statistical Package for the Social Sciences 19.0 (SPSS Armonk, NY: IBM Corp.)" was used for all analyses. Kolmogorov-Smirnov test and histograms were used to determine whether there was a normal distribution. The non-parametric data of the groups were compared using the Mann-Whitney U test and the parametric data using the ındependent t test. Chi-square test was used to test categorical data. Cases with P < 0.05 were considered statistically significant. : While 22 (6.2%) patients had renal insufficiency, 332 (95.8%) patients did not have renal insufficiency. In the evaluation made in terms of AP severity; according to Balthazar classification at admission, there was no difference in mild and moderate pancreatitis for kidney insufficiency in both groups, but it was significantly higher in the group with severe pancreatitis [2 (9.1%) versus 1 (0.3%), P < 0.001]. In the evaluation made after 72 hours; renal failure was significantly lower in the group with mild pancreatitis [11 (50.0%) versus 245 (73.8%), P: 0.016] and severe renal failure was significantly higher in severe pancreatitis [7 (31.8%) versus 13 (%) 3.9), P < 0.001]. Early intensive care unit admission and close follow-up and early treatment in AP patients change the course of the disease. In our study, we showed that serum creatinine level is an important parameter in the course of AP and has a predictive value for the course of the disease.

Risk Prediction Models for Early ICU Admission in Patients With Autoimmune Encephalitis: Integrating Scale-Based Assessments of the Disease Severity.

BackgroundIn patients with autoimmune encephalitis (AE), the prediction of progression to a critically ill status is challenging but essential. However, there is currently no standard prediction model that comprehensively integrates the disease severity and other clinical features. The clinical assessment scale in autoimmune encephalitis (CASE) and the modified Rankin Scale (mRS) have both been applied for evaluating the severity of AE. Here, by combining the two scales and other clinical characteristics, we aimed to investigate risk factors and construct prediction models for early critical care needs of AE patients.MethodsDefinite and probable AE patients who were admitted to the neurology department of Tongji Hospital between 2013 and 2021 were consecutively enrolled. The CASE and mRS scores were used to evaluate the overall symptom severity at the time of hospital admission. Using logistic regression analysis, we analyzed the association between the total scores of the two scales and critical illness individually and then we evaluated this association in combination with other clinical features to predict early intensive care unit (ICU) admission. Finally, we constructed four prediction models and compared their performances.ResultsOf 234 patients enrolled, forty developed critical illness and were early admitted to the ICU (within 14 days of hospitalization). Four prediction models were generated; the models were named CASE, CASE-plus (CASE + prodromal symptoms + elevated fasting blood glucose + elevated cerebrospinal fluid (CSF) white blood cell (WBC) count), mRS and mRS-plus (mRS + prodromal symptoms + abnormal EEG results + elevated fasting blood glucose + elevated CSF WBC count) and had areas under the ROC curve of 0.850, 0.897, 0.695 and 0.833, respectively. All four models had good calibrations. In general, the models containing “CASE” performed better than those including “mRS”, and the CASE-plus model demonstrated the best performance.ConclusionOverall, the symptom severity at hospital admission, as defined by CASE or mRS, could predict early ICU admission, especially when assessed by CASE. Adding other clinical findings, such as prodromal symptoms, an increased fasting blood glucose level and an increased CSF WBC count, could improve the predictive efficacy.

COVID-19 Disease Burden Related to Social Vulnerability and Comorbidities: Challenges to Tuberculosis Control.

Purpose: The first coronavirus disease (COVID-19) spike and subsequent pandemic in South Korea were rapid and disruptive. Government response measures for disadvantaged groups against infectious disease should be prioritized based on evidence and affordability. We investigated whether COVID-19 infection, intensive care unit (ICU) care, and mortality from COVID-19 are related to social and medical vulnerability, including tuberculosis (TB). Patients and Methods: Using the National Health Insurance Service COVID-19 database in South Korea, we analyzed 129,128 patients, including controls, from 1 January to 30 May 2020, during the early stage of the COVID-19 epidemic. The relationship between health insurance premiums (representing socioeconomic status), the Charlson comorbidity index (CCI) score for the severity of the underlying disease, and additional TB diagnosis was analyzed using the chi-square test and logistic regression. Results: For the demographics, 3244 out of 51,783 men (6.3%) and 4836 out of 77,345 women (6.3%) were infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). COVID-19 infection, ICU care, and mortality were related to older age (p < 0.001) and lower health insurance premium levels (p < 0.05). Regarding the CCI score, the CCI score, COVID-19 infection, and mortality increased (p < 0.0001). In terms of premium level, the highest group showed a lower risk of infection (OR 0.52, 0.48-0.57, p = 0.004), ICU care (OR 0.59, 0.46-0.75, p < 0.001), and mortality (OR 0.51, 0.32-0.78, p = 0.016) than the medical aid group. TB was related to ICU care for COVID-19 (OR 4.27, 1.27-14.38, p = 0.018). Conclusion: In the early epidemic, SARS-CoV-2 infection, ICU admission, and mortality from COVID-19 increased in socioeconomically and physically vulnerable groups. However, the relationship between tuberculosis, COVID-19 and mortality was not definite because of the possible under-reporting of TB cases and the relatively small number of TB patients.

Nationwide retrospective study of critically ill adults with sickle cell disease in France

Little is known about patients with sickle cell disease (SCD) who require intensive care unit (ICU) admission. The goals of this study were to assess outcomes in patients admitted to the ICU for acute complications of SCD and to identify factors associated with adverse outcomes. This multicenter retrospective study included consecutive adults with SCD admitted to one of 17 participating ICUs. An adverse outcome was defined as death or a need for life-sustaining therapies (non-invasive or invasive ventilation, vasoactive drugs, renal replacement therapy, and/or extracorporeal membrane oxygenation). Factors associated with adverse outcomes were identified by mixed multivariable logistic regression. We included 488 patients admitted in 2015–2017. The main reasons for ICU admission were acute chest syndrome (47.5%) and severely painful vaso-occlusive event (21.3%). Sixteen (3.3%) patients died in the ICU, mainly of multi-organ failure following a painful vaso-occlusive event or sepsis. An adverse outcome occurred in 81 (16.6%; 95% confidence interval [95% CI], 13.3%–19.9%) patients. Independent factors associated with adverse outcomes were low mean arterial blood pressure (adjusted odds ratio [aOR], 0.98; 95% CI 0.95–0.99; p = 0.027), faster respiratory rate (aOR, 1.09; 95% CI 1.05–1.14; p < 0.0001), higher haemoglobin level (aOR, 1.22; 95% CI 1.01–1.48; p = 0.038), impaired creatinine clearance at ICU admission (aOR, 0.98; 95% CI 0.97–0.98; p < 0.0001), and red blood cell exchange before ICU admission (aOR, 5.16; 95% CI 1.16–22.94; p = 0.031). Patients with SCD have a substantial risk of adverse outcomes if they require ICU admission. Early ICU admission should be encouraged in patients who develop abnormal physiological parameters.

Evaluation of the Initial General Ward Early Warning Score and ICU Admission, Hospital Length of Stay and Mortality.

IntroductionDespite widespread implementation of the Early Warning Score (EWS) in hospitals, its effect on patient outcomes remains mostly unknown. We aimed to evaluate associations between the initial EWS and in-hospital mortality, intensive care unit (ICU) admission, and hospital length of stay (LOS).MethodsWe performed a retrospective cohort study of adult patients admitted to a general hospital ward between July 1, 2014–December 31, 2017. Data were obtained from electronic health records (EHR). The primary outcome was in-hospital mortality. Secondary outcomes were ICU admission and hospital LOS. We categorized patients into three risk groups (low, medium or high risk of clinical deterioration) based on EWS. Descriptive analyses were used.ResultsAfter applying inclusion and exclusion criteria, we included 53,180 patients for analysis. We found that the initial (low- vs high-risk) EWS was associated with an increased in-hospital mortality (1.5% vs 25.3%, P <0.001), an increased ICU admission rate (3.1% vs 17.6%, P <0.001), and an extended hospital LOS (4.0 days vs 8.0 days, P <0.001).ConclusionOur findings suggest that an initial high-risk EWS in patients admitted to a general hospital ward was associated with an increased risk of in-hospital mortality, ICU admission, and prolonged hospital LOS. Close monitoring and precise documentation of the EWS in the EHR may facilitate predicting poor outcomes in individual hospitalized patients and help to identify patients for whom timely and adequate management may improve outcomes.

Association between early intensive care or coronary care unit admission and post-discharge performance of activities of daily living in patients with acute decompensated heart failure.

The management of acute decompensated heart failure often requires intensive care. However, the effects of early intensive care unit/coronary care unit admission on activities of daily living (ADL) in acute decompensated heart failure patients have not been precisely evaluated. Thus, we retrospectively assessed the association between early intensive care unit admission and post-discharge ADL performance in these patients. Acute decompensated heart failure patients (New York Heart Association I–III) admitted on emergency between April 1, 2014, and December 31, 2018, were selected from the Diagnosis Procedure Combination database and divided into intensive care unit/coronary care unit (ICU) and general ward (GW) groups according to the hospitalization type on admission day 1. The propensity score was calculated to create matched cohorts where admission style (intensive care unit/coronary care unit admission) was independent of measured baseline confounding factors, including ADL at admission. The primary outcome was ADL performance level at discharge (post-ADL) defined according to the Barthel index. Secondary outcomes included length of stay and total hospitalization cost (expense). Overall, 12231 patients were eligible, and propensity score matching created 2985 pairs. After matching, post-ADL was significantly higher in the ICU group than in the GW group [mean (standard deviation), GW vs. ICU: 71.5 (35.3) vs. 78.2 (31.2) points, P<0.001; mean difference: 6.7 (95% confidence interval, 5.1–8.4) points]. After matching, length of stay was significantly shorter and expenses were significantly higher in the ICU group than in the GW group. Stratified analysis showed that the patients with low ADL at admission (Barthel index score <60) were the most benefited from early intensive care unit/coronary care unit admission. Thus, early intensive care unit/coronary care unit admission was associated with improved post-ADL in patients with emergency acute decompensated heart failure admission.

Intensive care unit admission and mortality risk prediction in covid19 patients with spectrum of comorbidities using clinical laboratory and CT severity score

Introduction: Treatment of patients with COVID-19 in intensive care unit (ICU) has been a significant challenge. Early detection of COVID-19 related severity is critical for timely management of such patients. This retrospective observational study aimed to evaluate clinical characteristics such as laboratory parameters, associated comorbidities, computed tomography (CT)-based semi-quantitative score, and cumulative correlative measurement of critically ill COVID-19 patients to assess the requirement for early ICU admission. Materials and methods: Data from the treatment record of COVID-19 patients with severe pneumonia was collected at a tertiary care governament medical institution from 1st May, 2020 to 30th May, 2020. Binary logistic regression analysis, specificities and sensitivities of maximum D-dimer, ferritin, other laboratory measures, and CT-based semi-quantitative score for outcome cutoffs were calculated to predict early indicators of ICU admission and mortality. Results: Of 200 severe COVID-19 patients, 48% had comorbidities while 40% had mortality. The ICU admission rate was 43.5%, in which non-invasive ventillation and mechanical ventilation support were 27.5% and 16% respectively. Hypertension was reported for the most prevalent comorbidities (48%) followed by diabetes mellitus (24%), respiratory diseases (10.5%), renal diseases (5%), and chronic heart diseases (10%). Optimal cutoff for ICU requirement was 17.2 for neutrophil lymphocyte ratio (NLR), 727 ng/mL for ferritin, 2.2 mg/L FEU for D-dimer and 362.5 mg/L for C-reactive protein (CRP). Significantly higher risk of death was reported for patients having CT score of 14.5 (p

Impact of early ICU admission for critically ill cancer patients: Post-hoc analysis of a prospective multicenter multinational dataset.

Early intensive care unit (ICU) admission, in Critically Ill Cancer Patients (CICP), is believed to have contributed to the prognostic improvement of critically ill cancer patients. The primary objective of this study was to assess the association between early ICU admission and hospital mortality in CICP. Retrospective analysis of a prospective multicenter dataset. Early admission was defined as admission in the ICU<24h of hospital admission. We assessed the association between early ICU admission and hospital mortality in CICP via survival analysis and propensity score matching. Of the 1011patients in our cohort, 1005 had data available regarding ICU admission timing and were included. Overall, early ICU admission occurred in 455 patients (45.3%). Crude hospital mortality in patients with early and delayed ICU admission was 33.6% (n=153) vs. 43.1% (n=237), respectively (P=0.02). After adjustment for confounders, early compared to late ICU admission was not associated with hospital mortality (HR 0.92; 95%CI 0.76-1.11). After propensity score matching, hospital mortality did not differ between patients with early (35.2%) and late (40.6%) ICU admission (P=0.13). In the matched cohort, early ICU admission was not associated with mortality after adjustment on SOFA score (HR 0.89; 95%CI 0.71-1.12). Similar results were obtained after adjustment for center effect. In this cohort, early ICU admission was not associated with a better outcome after adjustment for confounder and center effect. The uncertainty with regard to the beneficial effect of early ICU on hospital mortality suggests the need for an interventional study.

Epidemiology, clinical features, and management of severe hypercalcemia in critically ill patients

BackgroundSevere hypercalcemia (HCM) is a common reason for admission in intensive-care unit (ICU). This case series aims to describe the clinical and biological features, etiologies, treatments, and outcome associated with severe HCM. This study included all patients with a total calcemia above 12 mg/dL (3 mmol/L) admitted in two ICUs from January 2007 to February 2017.Results131 patients with HCM were included. HCM was related to hematologic malignancy in 58 (44.3%), solid tumors in 29 (22.1%), endocrinopathies in 16 (12.2%), and other causes in 28 (21.3%) patients. 108 (82.4%) patients fulfilled acute kidney injury (AKI) criteria. Among them, 25 (19%) patients required renal replacement therapy (RRT). 51 (38.9%) patients presented with neurological symptoms, 73 (55.7%) patients had cardiovascular manifestations, and 50 (38.1%) patients had digestive manifestations. The use of bisphosphonates (HR, 0.42; 95% CI, 0.27–0.67; P < 0.001) was the only treatment significantly associated with a decrease of total calcemia below 12 mg/dL (3 mmol/L) at day 5. ICU and Hospital mortality rates were, respectively, 9.9% and 21.3%. Simplified Acute Physiologic Score (SAPS II) (OR, 1.05; 95% CI 1.01–1.1; P = 0.03) and an underlying solid tumor (OR, 13.83; 95% CI 2.24–141.25; P = 0.01) were two independent factors associated with hospital mortality in multivariate analysis.ConclusionsHCM is associated with high mortality rates, mainly due to underlying malignancies. The course of HCM may be complicated by organ failures which are most of the time reversible with early ICU management. Early ICU admission and prompt HCM management are crucial, especially in patients with an underlying solid tumor presenting with neurological symptoms.

Mortality of ischemic stroke patients admitted to the intensive care unit in Sultan Qaboos University Hospital

Background: Haemorrhagic and ischemic stroke is the second most common cause of death worldwide, with more than 10 million cases each year1. Hypertension, diabetes mellitus, smoking, hyperlipidemia, and aging are the most common risk factors of this cerebrovascular disease2. Mortality and disability increase with the complications experienced during the early phase of stroke, such as infection, seizures, and thromboembolism3. The intensive care unit (ICU) is the most appropriate treatment environment for stroke patient care in developing countries4. Aims: The aims of this study were to determine the ICU and in-hospital mortality of ischemic stroke patients admitted to the ICU within 24 hours of hospitalization, and the factors that determine and affect the outcomes of ischemic stroke to predict patients requiring early ICU admission. Methods: This is a retrospective study looking at the data of patients admitted to the intensive care unit in Sultan Qaboos University Hospital (SQUH) with an ischemic stroke diagnosis within 24 hours of hospitalization from 1st January 2013 to 31th December 2017. Results: There were 37 patients admitted to the ICU immediately from the emergency department because of ischemic stroke during the study period. There were 14 patients who died in the ICU, 2 died in-hospital after discharge from ICU, and the others were discharged from hospital (Table 1). There were 21 male patients and 16 females, with a mean age of 61.05 years. Most patients had comorbidities and risk factors that lead to poor outcome, the most common being diabetes mellitus (70.3%) and hypertension (67.6%). However, there was no association between blood pressure and glycemic control on admission with outcome (chi-square test, p = (0.667), (0.505) respectively). CT, MRI, and CT angiography are the most common diagnostic imaging tools used for ischemic stroke. We classified CT brain findings on admission according to the location of infarction. Middle cerebral artery infarction was present in 40.5% of the patients, 18.9% had other cerebral infarction, 10.8% had brain stem infarction, and the same proportion of patients had lacunar infarction, and the rest showed no abnormality. The two main reasons for admission to ICU were coma (73.0%) and neurological monitoring post-thrombolysis (24.3%). The rest were admitted because of respiratory failure. In ICU, 48.6% received intravenous thrombolysis and the majority of patients were discharged. Others were out of the therapeutic window and had a high chance of haemorrhagic transformation. Patients developed complications after ICU admission as shown in Figure 1. There was a significant association between ICU mortality and ICU complications, (chi-square test, p < 0.05). Conclusion: The mortality of ischemic stroke patients admitted to ICU within 24 hours of hospitalization in the study period was 43.2% with higher prevalence among older and male patients. The majority of these patients had comorbidities and risk factors that lead to a poor outcome. The main two reasons for admission to ICU were impaired consciousness and neurological monitoring post-thrombolysis. The outcome can be improved by preventing such complications and therefore reducing ICU mortality. More studies are recommended to find more factors that can predict the outcome of ischemic stroke.

Multiple Organ Dysfunction Syndrome.

Multiple organ dysfunction syndrome (MODS) is one of the most common syndromes of critical illness and the leading cause of mortality among critically ill patients. Multiple organ dysfunction syndrome is the clinical consequence of a dysregulated inflammatory response, triggered by clinically diverse factors with the main pillar of management being invasive organ support. During the last years, the advances in the clarification of the molecular pathways that trigger, mitigate, and determine the outcome of MODS have led to the increasing recognition of MODS as a distinct disease entity with distinct etiology, pathophysiology, and potential future therapeutic interventions. Given the lack of effective treatment for MODS, its early recognition, the early intensive care unit admission, and the initiation of invasive organ support remain the most effective strategies of preventing its progression and improving outcomes.

Preoperative Factors Predicting Admission to the Intensive Care Unit After Kidney Transplantation.

ObjectiveTo identify preoperative factors predicting early admission (within 30 days) of adult kidney transplant recipients to the intensive care unit (ICU).Patients and MethodsThis is a single-center retrospective study of consecutive kidney transplant recipients between January 1, 2007, and December 31, 2016. Children (aged <18 years) and patients who underwent simultaneous multiorgan transplantation were excluded from the analysis. Associations between demographic, transplant-related, and comorbidity variables with ICU admission within 30 days of transplantation were analyzed using univariate and multivariate logistic regression models.ResultsOf the 1527 eligible patients, 305 (20%) required early ICU admission. In univariate analysis, older age, higher body mass index (BMI), previous transplantation, myocardial infarction, congestive heart failure, obstructive pulmonary disease, longer ischemia time, pretransplant dialysis, and transplantation from a deceased donor were associated with increased odds of ICU admission. After multivariate adjustment, every 10-year increase in recipient age (odds ratio [OR], 1.26; 95% CI, 1.12-1.42; P<.001), 5-unit increase in BMI (OR, 1.11; 95% CI, 1.00-1.22; P=.049), pretransplant dialysis (OR, 1.57; 95% CI, 1.19-2.08; P=.002), and deceased donor transplantation (OR, 1.82; 95% CI, 1.29-2.55; P<.001) were associated with the increased risk of ICU admission. Preemptive transplantation (OR, 0.64; 95% CI, 0.48-0.84; P=.002) and living donor kidney transplantation (OR, 0.55; 95% CI, 0.39-0.77; P<.001) were associated with lower odds of ICU admission after transplantation.ConclusionRecipient age, BMI, and the need for pretransplant dialysis are associated with a higher risk of early ICU admission after kidney transplantation, whereas living donor kidney transplantation and preemptive transplantation decrease these odds. Early referral of patients with end-stage renal disease for preemptive transplantation and living donor kidney transplantation can significantly reduce transplant-related ICU admissions.

Acute Respiratory Failure in Renal Transplant Recipients: A Single Center Experience.

We evaluated the frequency and cause of acute respiratory failure in renal transplant recipients. Our single-center retrospective observational study included consecutive renal transplant recipients who were admitted to an intensive care unit for acute respiratory failure between 2011 and 2017. Acute respiratory failure was defined as oxygen saturation < 92% or partial pressure of oxygen in arterial blood < 60 mm Hg on room air and/or requirement of noninvasive or invasive mechanical ventilation. Of 187 renal transplant recipients, 35 (18.71%) required intensive care unit admission; 11 of these patients (31.4%) were admitted to the intensive care unit with acute respiratory failure. Six of these patients (54.5%) had pneumonia and had shown infiltrates on chest radiography, which were shown in a minimum of 3 zones of the lung (2 with Klebsiella pneumonia, 1 with Acinetobacter species, 1 with Proteus mirabilis, 2 with no microorganisms). The other reasons for acute respiratory failure were cardiogenic pulmonary edema (2 patients), acute respiratory distress syndrome (2 patients, due to acute pancreatitis and acute cerebrovascular thromboembolism), and exacerbation of chronic obstructive pulmonary disease (1 patient). Six patients (54.5%) needed invasive mechanical ventilation because of pneumonia (3 patients), cardiogenic pulmonary edema (2 patients), and cerebrovascular thromboembolism (1 patient). Hemodialysis was administered in 5 patients (45%). Six of 11 patients died due to pneumonia (3 p atients), cardiogenic pulmonary edema (2 patients), and cerebrovascular thromboembolism (1 patient). Among the 5 survivors, 3 (60%) had recovered previous graft function. Acute respiratory failure is associated with high mortality and morbidity in renal transplant recipients. Main causes of acute respiratory failure were bacterial pneumonia and cardiogenic pulmonary edema in our study population. Extended chemoprophylaxis for bacterial and fungal infection and early intensive care unit admission of patients with acute respiratory failure may improve outcomes.

Allogeneic stem cell transplantation recipients requiring intensive care: time is of the essence.

The benefit of early admission of allogeneic stem cell transplantation (SCT) recipients to the intensive care unit (ICU) as soon as they develop organ injury is unknown. We performed a retrospective study on 92 patients admitted to the ICU to determine the impact of time from organ injury to ICU admission on outcome. The number of organ injuries prior to ICU admission was associated with an increased in-hospital mortality (OR 1.7, 95% CI 1-2.7, p = 0.04). Time between first organ injury and ICU admission was also associated with an increased in-hospital survival (OR 1.4, 95% CI 1.1-1.8, p = 0.02). A score combining these two covariates-the number of organ injuries/day (sum of days spent with each individual organ injury)-further improved the prediction of hospital survival. Patients with more organ injuries/day had significantly higher in-hospital mortality rate even after adjustment for refractory acute GVHD and the SOFA (OR 1.3, 95% CI 1-1.7, p = 0.02). Early ICU admission of allogeneic SCT recipients to the ICU as soon as they develop organ injury is associated with decreased in-hospital mortality.

Secondary hemophagocytic lymphohistiocytosis syndrome in adults: A case series and review of the literature

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life threatening condition characterized by immune dysregulation and benign proliferation of phagocytic cells, macrophages, and histiocytes. Lymphocytes (CD8 T-cells and natural killer cells) also play a major role in HLH. The ensuing cytokine storm and blood cells phagocytosis can lead to fatal multiple organ failure. So any diseases that can lead to activation of these cytokines can lead to hemophagocytic syndrome. 5 adult patients presented to Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia during 2014–2016 and fulfill the diagnostic criteria of HLH according to HLH-2004 diagnostic and therapeutic guidelines for HLH , have been included in this case series. Two out of five had viral infection, one patient was diagnosed with tuberculosis, and one patient developed secondary HLH in due to malignancy. The fifth patient did not have an identiable etiology. All of our patients presented with different symptoms and were diagnosed based on the standard approved criteria. Only two Out of five patients survived and remained disease free for a follow-up period of 24 months. As a conclusion, HLH syndrome is a rare condition with a high mortality rate. Aggressive treatment approach and early Intensive Care Unit admission is strongly recommended in patients with the cardinal diagnostic features of this condition.

Abstract 13175: Outcomes of Heart Failure (HF) Patients Admitted to the Intensive Care Unit (ICU): Impact of Early or Late ICU Admission

Background: Little is known about the outcomes of HF patients who are admitted to an ICU. We examined the outcomes of HF patients who were admitted to directly to the ICU (early) or admitted to the ICU after initial ward admission (late), compared to non-ICU admitted patients. Methods: We examined 118,595 HF patients (ICD-10 code I50) in Ontario, Canada, who were hospitalized from 2003-2012 using the Canadian Institute for Health Information Discharge Abstract Database. We examined the association of ICU admission and timing with: a) 30-day mortality using multiple Cox regression with time-varying covariates, and b) 30-day hospital readmissions using repeated events analysis approach of Prentice, Williams and Peterson. Results: Of the cohort, 24,119 (20%) were admitted to an ICU during the hospital stay, of whom 84% were admitted early (median age 76 years, 54% men) and 16% were admitted later (age 77 years, 53% men). 30-day mortality was higher in early and late ICU compared to no ICU: 13%, 27%, 10.5% (p &lt;.001). Multivariable-adjusted hazard ratios (HR) were: 1.65 (95%CI; 1.58-1.73) for early ICU (p&lt;.001) and 4.59 (95%CI; 4.31-4.89) for late ICU (p&lt;.001) vs. no ICU (referent). All-cause 30-day readmissions were also highest among late ICU, followed by early ICU, and lowest in non-ICU patients: 24.3, 22.9, 21.7 readmissions per 100 person-months (all p &lt;.001). Multivariable-adjusted repeated events analysis demonstrated a progressively increasing HRs for all-cause readmission: 1.07 (95%CI; 1.04-1.11) for early ICU (p&lt;.001) and 1.13 (95%CI; 1.04-1.22) for late ICU (p&lt;.01) vs. no ICU (referent). Median in-hospital costs were $16,553 for late ICU, $8587 for early ICU, and $7296 for non-ICU admitted patients (p &lt;.001). Conclusions: HF patients who are admitted to the ICU are sicker and experience increased risk of 30-day readmissions and death. Late ICU admissions were associated with the highest risk of death and readmission, and incurred substantially higher costs of care.

Postoperative Pulmonary Complications, Early Mortality, and Hospital Stay Following Noncardiothoracic Surgery

Postoperative pulmonary complications (PPCs), a leading cause of poor surgical outcomes, are heterogeneous in their pathophysiology, severity, and reporting accuracy. To prospectively study clinical and radiological PPCs and respiratory insufficiency therapies in a high-risk surgical population. We performed a multicenter prospective observational study in 7 US academic institutions. American Society of Anesthesiologists physical status 3 patients who presented for noncardiothoracic surgery requiring 2 hours or more of general anesthesia with mechanical ventilation from May to November 2014 were included in the study. We hypothesized that PPCs, even mild, would be associated with early postoperative mortality and use of hospital resources. We analyzed their association with modifiable perioperative variables. Noncardiothoracic surgery. Predefined PPCs occurring within the first 7 postoperative days were prospectively identified. We used bivariable and logistic regression analyses to study the association of PPCs with ventilatory and other perioperative variables. This study included 1202 patients who underwent predominantly abdominal, orthopedic, and neurological procedures. The mean (SD) age of patients was 62.1 (13.8) years, and 636 (52.9%) were men. At least 1 PPC occurred in 401 patients (33.4%), mainly the need for prolonged oxygen therapy by nasal cannula (n = 235; 19.6%) and atelectasis (n = 206; 17.1%). Patients with 1 or more PPCs, even mild, had significantly increased early postoperative mortality, intensive care unit (ICU) admission, and ICU/hospital length of stay. Significant PPC risk factors included nonmodifiable (emergency [yes vs no]: odds ratio [OR], 4.47, 95% CI, 1.59-12.56; surgical site [abdominal/pelvic vs nonabdominal/pelvic]: OR, 2.54, 95% CI, 1.67-3.89; and age [in years]: OR, 1.03, 95% CI, 1.02-1.05) and potentially modifiable (colloid administration [yes vs no]: OR, 1.75, 95% CI, 1.03-2.97; preoperative oxygenation: OR, 0.86, 95% CI, 0.80-0.93; blood loss [in milliliters]: OR, 1.17, 95% CI, 1.05-1.30; anesthesia duration [in minutes]: OR, 1.14, 95% CI, 1.05-1.24; and tidal volume [in milliliters per kilogram of predicted body weight]: OR, 1.12, 95% CI, 1.01-1.24) factors. Postoperative pulmonary complications are common in patients with American Society of Anesthesiologists physical status 3, despite current protective ventilation practices. Even mild PPCs are associated with increased early postoperative mortality, ICU admission, and length of stay (ICU and hospital). Mild frequent PPCs (eg, atelectasis and prolonged oxygen therapy need) deserve increased attention and intervention for improving perioperative outcomes.

Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis.

The outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients has significantly improved over the past decade. Still, a significant number of patients require intensive care unit (ICU) management because of life-threatening complications. Literature from the 1990s reported extremely poor prognosis for critically ill allo-HSCT patients requiring ICU management. Recent data justify the use of ICU resources in hematologic patients. Yet, allo-HSCT remains an independent variable associated with mortality. However, outcomes in allo-HSCT patients have improved over time and many classic determinants of mortality have become irrelevant. The main actual prognostic factors are the need for mechanical ventilation, the presence of GvHD and the number of organ failures at ICU admission. Recently, the development of reduced-intensity conditioning regimens, early ICU admission and the increased use of noninvasive ventilation, combined with time effect and general advances in hematology, in allo-HSCT procedures and in ICU management have contributed to improve general outcome. A rational policy of ICU admission triage in these patients is very hard to define, as each decision for ICU admission is a case-by-case decision at patient bedside. The collaboration between hematologists and intensivists is crucial in this context.