Failure In Intensive Care Unit Research Articles

Incidence, Risk Factors, and Long-Term Outcomes for Extubation Failure in ICU in Patients With Obesity: A Retrospective Analysis of a Multicenter Prospective Observational Study

BackgroundNo large observational study has compared the incidence and risk factors for extubation failure within 48 hours and during intensive care unit (ICU) stay in the same cohort of unselected critically ill patients with and without obesity. Research questionWhich are the incidence and risk factors of extubation failure in patients with and without obesity? Study design and methodsIn this prospective multicenter observational FREE-REA study in 26 intensive care units, the primary objective was to compare the incidence of extubation failure within 48 hours in patients with and without obesity. Secondary objectives were to describe and to identify the independent specific risk factors for extubation failure using first a logistic regression model and second a decision tree analysis. ResultsOf 1,370 extubation procedures analyzed, 288 (21%) were performed in patients with obesity and 1082 (79%) in patients without obesity. The incidence of extubation failure within 48 hours among patients with or without presence of obesity was 23/288 (8.0%) versus 118/1082 (11%) respectively; unadjusted odds ratio (OR) 0.71 95% confidence interval (CI, 0.45-1.13), P=0.15); alongside patients with obesity receiving significantly more noninvasive ventilation (87/288, 30% versus 233/1082, 22%, P=0.002) and physiotherapy (165/288, 57% versus 527/1082, 49%, P=0.02) than patients without obesity. Risk factors for extubation failure also differed according to obesity status: female gender [adjusted (a)OR 4.88 95%CI(1.61-13.9), P=0.002] and agitation before extubation [aOR 6.39 95%CI (1.91-19.8), P=0.001] in patients with obesity; absence of strong cough before extubation [aOR 2.38 95%CI (1.53-3.84), P=0.0002] and duration of invasive mechanical ventilation before extubation [aOR 1.03 per day 95%CI (1.01-1.06), P=0.01] in patients without obesity. The decision tree analysis found similar risk factors. InterpretationOur findings indicate that anticipation and application of preventive measures for patients with obesity before and after extubation led to similar rate of extubation failure among patients with and without obesity. Clinical trial registrationNCT XXX

Prediction of mortality events of patients with acute heart failure in intensive care unit based on deep neural network

BackgroundAcute heart failure (AHF) in the intensive care unit (ICU) is characterized by its criticality, rapid progression, complex and changeable condition, and its pathophysiological process involves the interaction of multiple organs and systems. This makes it difficult to predict in-hospital mortality events comprehensively and accurately. Traditional analysis methods based on statistics and machine learning suffer from insufficient model performance, poor accuracy caused by prior dependence, and difficulty in adequately considering the complex relationships between multiple risk factors. Therefore, the application of deep neural network (DNN) techniques to the specific scenario, predicting mortality events of patients with AHF under intensive care, has become a research frontier. MethodsThis research utilized the MIMIC-IV critical care database as the primary data source and employed the synthetic minority over-sampling technique (SMOTE) to balance the dataset. Deep neural network models—backpropagation neural network (BPNN) and recurrent neural network (RNN), which are based on electronic medical record data mining, were employed to investigate the in-hospital death event judgment task of patients with AHF under intensive care. Additionally, multiple single machine learning models and ensemble learning models were constructed for comparative experiments. Moreover, we achieved various optimal performance combinations by modifying the classification threshold of deep neural network models to address the diverse real-world requirements in the ICU. Finally, we conducted an interpretable deep model using SHapley Additive exPlanations (SHAP) to uncover the most influential medical record features for each patient from the aspects of global and local interpretation. ResultsIn terms of model performance in this scenario, deep neural network models outperform both single machine learning models and ensemble learning models, achieving the highest Accuracy, Precision, Recall, F1 value, and Area under the ROC curve, which can reach 0.949, 0.925, 0.983, 0.953, and 0.987 respectively. SHAP value analysis revealed that the ICU scores (APSIII, OASIS, SOFA) are significantly correlated with the occurrence of in-hospital fatal events. ConclusionsOur study underscores that DNN-based mortality event classifier offers a novel intelligent approach for forecasting and assessing the prognosis of AHF patients in the ICU. Additionally, the ICU scores stand out as the most predictive features, which implies that in the decision-making process of the models, ICU scores can provide the most crucial information, making the greatest positive or negative contribution to influence the incidence of in-hospital mortality among patients with acute heart failure.

Effect of predictive nursing based on risk early warning system on patients with acute respiratory failure in Intensive Care Unit.

Acute respiratory failure (ARF) is a life-threatening condition that necessitates intensive care and often results in high morbidity and mortality. Predictive nursing, combined with a risk early warning system, offers a proactive approach to patient care that could potentially improve outcomes in patients with ARF. However, the efficiency of this approach in intensive care settings is still unclear. This study aimed to analyze the effect of predictive nursing based on risk early warning system in patients with acute respiratory failure in intensive care unit (ICU) setting. A retrospective cohort study included records of 368 patients admitted to ICU of a tertiary care hospital due to ARF from January 2021 to January 2023. Patients were divided into two groups based on the received care: standard care (control group, n=197) and predictive nursing care based on a risk early warning system (observation group, n=171). Data on demographics, clinical characteristics, complications, Acute Physiology, Age and Chronic Health Evaluation-II (APACHE-II) and Sequential Organ Failure Assessment (SOFA) scores, and duration of hospitalization were collected and analyzed. The observation group exhibited significantly lower incidence of complications related to ventilator use and shorter durations of mechanical ventilation, ICU stay, and total hospitalization compared to the control group (p<0.001). Furthermore, patients in the observation group had significantly lower APACHE-II and SOFA scores and blood lactate levels at both one week and two weeks post-intervention. Predictive nursing care based on a risk early warning system significantly improved clinical outcomes and reduced mortality rates in ICU patients with ARF. The results underscore the potential of integrating predictive nursing care into routine practice, thereby transforming the care paradigm for ICU patients with ARF. Future research should explore the applicability of predictive nursing for other clinical conditions and in various healthcare settings.

Association of Age, Frailty, and Strategy for Initiation of Renal-Replacement Therapy: A Post Hoc analysis of the STARRT-Acute Kidney Injury Trial

Plain Language SummaryThis study was designed to assess the association of age and frailty with clinical outcomes in patients with severe acute kidney failure using the data from an international randomized trial called the STARRT-AKI trial that examined the effect of timing of dialysis initiation on mortality in patients with acute kidney failure. In this study, older age was defined as ≥65 years, accounting for more than a half of the study population. This study demonstrated that older and frail patients carried higher mortality rates. However, age and frailty did not appear to have a significant impact on kidney recovery. Furthermore, in older or frail patients, timing of initiation of dialysis therapy did not affect mortality and kidney recovery. These findings will assist with triaging, prognostication, and management of older and frail patients with severe acute kidney failure in intensive care units.

Factor for Predicting Non-Invasive Ventilation Failure in Very Old Patients with Hypoxemic Respiratory Failure in Intensive Care Unit

Aims: This study aimed to investigate the efficacy of NIV in patients with pneumonia-associated acute hypoxemic respiratory failure (AHRF) and to identify factors that predict NIV failure. Methods: A total of 50 very elderly patients (aged 85 and older) with pneumonia-associated AHRF were retrospectively evaluated from January 2021 to August 2022. Failure of NIV was defined was characterized by a transition to mechanical ventilation (either through tracheal intubation or tracheostomy), discharge under "hopeless" conditions while still on NIV, or death during NIV. Results: The mean age of the patients was 87.4±2.4 years, median SOFA score was 5, median duration of NIV was 4 days, and median length of stay in the ICU for the patients was 7 days. It was determined that 48% of the patients experienced NIV failure due to worsening clinical conditions. The SOFA score, levels of procalcitonin, CRP, heart rate, and respiratory rate were higher in the NIV failure group compared to the NIV successful group. An increased SOFA score (OR= 1.51, 95% CI= 1.11-2.06, p= 0.009), elevated CRP levels (OR= 1.03, 95% CI= 1.01-1.05, p= 0.003), and increased respiratory rate (OR= 1.18, 95% CI= 1.01-1.38, p= 0.039) were identified as independent predictors of NIV failure. Conclusion: In very elderly patients with AHRF due to pneumonia, the use of NIV may offer a significant survival benefit if patients are closely monitored and potential risk factors such as systemic inflammation parameters, SOFA score, and respiratory rate are considered.

Effect of trehalose on mortality and disease severity in ICU-admitted patients: Protocol for a triple-blind, randomized, placebo-controlled clinical trial

BackgroundImprovement in organ failure in intensive care unit (ICU) patients is accompanied by lower mortality rate. A disaccharide, trehalose is a candidate to improve organ failure and survival by autophagy induction and enhancing oxidative stress defense. The aim of this study is to assess the effectiveness of trehalose in improving clinical outcome and reducing mortality in ICU patients. Methodsa triple-blind, randomized, placebo-controlled, two arm, parallel-group, superiority clinical trial will enroll 200 ICU-admitted patients at Imam Reza hospital, Mashhad, Iran. The patients will be randomly allocated to receive either a 100 ml solution of 15 % trehalose or normal saline intravenously. Primary outcomes include ICU mortality and 60-day mortality, while secondary outcomes focus on blood parameters on day 5 and length of hospital/ICU stay. ConclusionTrehalose has demonstrated beneficial effects in diverse patients; however, no study has evaluated its effect in all ICU-admitted patients. Consequently, this study provides an opportunity to investigate whether trehalose's anti-inflammatory effects, mediated by inducing autophagy and enhancing oxidative stress defense, can play a role in reducing mortality and improving clinical outcomes in the critically ill patients. If successful, trehalose could offer a potential therapeutic approach in the ICU setting.

Development and validation of a new prognostic model for patients with acute-on-chronic liver failure in intensive care unit.

Cirrhotic patients with acute-on-chronic liver failure (ACLF) in the intensive care unit (ICU) have a poor but variable prognoses. Accurate prognosis evaluation can guide the rational management of patients with ACLF. However, existing prognostic scores for ACLF in the ICU environment lack sufficient accuracy. To develop a new prognostic model for patients with ACLF in ICU. Data from 938 ACLF patients in the Medical Information Mart for Intensive Care (MIMIC) database were used to develop a new prognostic model (MIMIC ACLF) for ACLF. Discrimination, calibration and clinical utility of MIMIC ACLF were assessed by area under receiver operating characteristic curve (AUROC), calibration curve and decision curve analysis (DCA), respectively. MIMIC ACLF was then externally validated in a multiple-center cohort, the Electronic Intensive Care Collaborative Research Database and a single-center cohort from the Second Hospital of Hebei Medical University in China. The MIMIC ACLF score was determined using nine variables: ln (age) × 2.2 + ln (white blood cell count) × 0.22 - ln (mean arterial pressure) × 2.7 + respiratory failure × 0.6 + renal failure × 0.51 + cerebral failure × 0.31 + ln (total bilirubin) × 0.44 + ln (internationalized normal ratio) × 0.59 + ln (serum potassium) × 0.59. In MIMIC cohort, the AUROC (0.81/0.79) for MIMIC ACLF for 28/90-day ACLF mortality were significantly greater than those of Chronic Liver Failure Consortium ACLF (0.76/0.74), Model for End-stage Liver Disease (MELD; 0.73/0.71) and MELD-Na (0.72/0.70) (all P < 0.001). The consistency between actual and predicted 28/90-day survival rates of patients according to MIMIC ACLF score was excellent and superior to that of existing scores. The net benefit of MIMIC ACLF was greater than that achieved using existing scores within the 50% threshold probability. The superior predictive accuracy and clinical utility of MIMIC ACLF were validated in the external cohorts. We developed and validated a new prognostic model with satisfactory accuracy for cirrhotic patients with ACLF hospitalized in the ICU. The model-based risk stratification and online calculator might facilitate the rational management of patients with ACLF.

U-Shaped Association between Serum Chloride Levels and In-Hospital Mortality in Patients with Congestive Heart Failure in Intensive Care Units.

Serum chloride level has clinical significance in the prognosis of heart failure. Little is known regarding the association between serum chloride levels and in-hospital mortality in patients with heart failure.This retrospective study used clinical data obtained from the Medical Information Mart for Intensive Care Database. The study cohort comprised patients who were categorized on the basis of their serum chloride levels, and the primary endpoint was in-hospital mortality. To assess the impact of serum chloride levels at the time of intensive care unit admission on in-hospital mortality, we used various statistical approaches, including multivariable logistic regression models, a generalized additive model, and a two-piecewise linear regression model. In addition, subgroup analysis was conducted to examine the robustness of the main findings.This study comprised 15,983 participants. When compared with the reference group (Q5), the groups with the highest (Q7) and lowest (Q1) blood chloride levels exhibited increased in-hospital mortality, with fully adjusted odds ratios (ORs) of 1.36 [95% confidence interval (CI): 1.08-1.71] and 1.25 (95% CI: 1-1.56), respectively. A U-shaped relationship was observed between blood chloride levels and in-hospital mortality, with the lowest risk observed at a threshold of 105.017 mmol/L. The effect sizes and corresponding CIs below and above the threshold were 0.969 (95% CI: 0.957-0.982) and 1.039 (95% CI: 1.002-1.076), respectively. Stratified analyses demonstrated the robustness of this correlation.The relationship between serum chloride levels and in-hospital mortality in patients with heart failure was U-shaped, with an inflection point of 105.017 mmol/L.

Comparison of non-COVID-19 critically ill patients between pre-pandemic and pandemic period admitted from emergency department to internal medicine intensive care unit

Aim: During the COVID-19 pandemic, a large number of intensive care unit beds have been organized for critically ill COVID-19 patients. However, the need for intensive care for non-COVID-19 critical patients continues. In our study, we aimed to compare non-COVID-19 critically ill patients admitted to the internal medicine intensive care unit from the emergency department before and during the pandemic period.&#x0D; Materials and Methods: Patients who were admitted to the internal medicine intensive care unit from the emergency department were grouped as pre-pandemic (March 2018-March 2020) and during the pandemic (March 2020-March 2022) and compared retrospectively in terms of the number of hospitalisations, demographic characteristics, length of intensive care unit stay and mortality.&#x0D; Results: The number of emergency department patient admissions other than surgical reasons was 579.657 during the study period. 63.33 % of these patients were admitted before the pandemic and 36.67% during the pandemic period. The number of patients included in our study was 493 before the pandemic and 460 during the pandemic period. Median age was 61 (30) in the pre-pandemic period and 64 (26.8) in the pandemic period, p=0.022. There was no significant difference in terms of comorbidities. The main reason for hospitalisation was similar and sepsis was the leading reason for hospitalisation. The frequency of acute renal failure in intensive care unit was significantly higher during the pandemic period. Mortality was 25.2% before the pandemic and 24.3% during the pandemic period, p=0.760.&#x0D; Conclusion: Although emergency department admissions decreased, the number of non-COVID-19 internal medicine intensive care unit hospitalisations did not decrease. This situation reveals the importance of organising intensive care beds for hospitalisation for non-COVID-19 reasons in order not to disrupt health services during the pandemic period.

A novel prognostic model to predict mortality in patients with acute-on-chronic liver failure in intensive care unit.

Acute-on-chronic liver failure (ACLF) implies high short-term mortality rates and usually requires intensive care unit (ICU) admission. Proper prognosis for these patients is crucial for early referral for liver transplantation. The superiority of CLIF-C ACLF score in Asian patients with ACLF admitted to an ICU remains inconclusive when compared to other scoring systems. The purpose of the study is (i) to compare the predictive performance of original MELD, MELD-Lactate, CLIF-C ACLF, CLIF-C ACLF-Lactate, and APACHE-II scores for short-term mortality assessment. (ii) to build and validate a novel scoring system and to compare its predictive performance to that of the original five scores. Two hundred sixty-five consecutive cirrhotic patients with ACLF who were admitted to our ICU were enrolled. The prognostic values for mortality were assessed by ROC analysis. A novel model was developed and internally validated using fivefold cross-validation. Alcohol abuse was identified as the primary etiology of cirrhosis. The AUROC of the five prognostic scores were not significantly superior to each other in predicting 1-month and 3-month mortality. The newly developed prognostic model, incorporating age, alveolar-arterial gradient (A-a gradient), BUN, total bilirubin level, INR, and HE grades, exhibited significantly improved performance in predicting 1-month and 3-month mortality with AUROC of 0.863 and 0.829, respectively, as compared to the original five prognostic scores. The novel ACLF model seems to be superior to the original five scores in predicting short-term mortality in ACLF patients admitted to an ICU. Further rigorous validation is required.

Effectiveness of high flow nasal cannula (HFNC) versus bilevel positive airway pressure (BiPAP) in preventing tracheal reintubation in patients with high risk of extubation failure in intensive care unit - A randomised comparative trial.

The incidence of tracheal extubation failure in high-risk patients is higher, and non-invasive ventilation is suggested to avoid tracheal reintubation. This study compares the effectiveness of bilevel positive airway pressure (BiPAP) and high flow nasal cannula (HFNC) to reduce the rate of reintubation in intensive care unit (ICU) patients with increased risk of extubation failure. This randomised comparative trial was conducted on 60 high-risk patients on mechanical ventilators admitted to the ICU, ready for weaning after a spontaneous breathing trial. They were randomised to Group H for HFNC and Group B for BiPAP therapy. Designated therapy was administered in these high-risk patients for up to 48 hours after tracheal extubation. Haemodynamic parameters [mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), a saturation of peripheral oxygen (SpO2), electrocardiogram (ECG)], arterial blood gas analysis (ABG) parameter [potential of hydrogen (pH), partial pressure of carbon dioxide (pCO2), partial pressure of oxygen/fraction of inspired oxygen (paO2/FiO2) ratio], the effectiveness of cough, comfort level was recorded and continuous monitoring for signs of respiratory distress and failure was done. Most of the patients were obese and had more than two risk factors for extubation failure. Several patients in Group B have significantly higher successful extubation than in Group H (P = 0.044). Most of the reintubation took place within 24 hours. The HFNC therapy was more comfortable and acceptable to patients. BiPAP therapy was more efficient than HFNC in preventing tracheal reintubation among patients with a high risk of extubation failure.

Adherence to low tidal volume in the transition to spontaneous ventilation in patients with acute respiratory failure in intensive care units in Latin America (SPIRAL): a study protocol

RESUMO Objetivo: Pacientes com insuficiência respiratória aguda frequentemente necessitam de ventilação mecânica para reduzir o trabalho respiratório e melhorar a troca gasosa; no entanto, a ventilação mecânica pode exacerbar a lesão pulmonar. As estratégias de ventilação protetora, caracterizadas por baixo volume corrente (≤ 8mL/kg de peso corporal previsto) e pressão de platô limitada abaixo de 30cmH2O, mostraram melhores desfechos em pacientes com síndrome do desconforto respiratório agudo. No entanto, na transição para a ventilação espontânea, manter o volume corrente dentro dos níveis de proteção pode ser desafiador, e não está claro se o volume corrente baixo durante a ventilação espontânea afeta os desfechos dos pacientes. Desenvolvemos um protocolo de estudo para estimar a prevalência de ventilação com volume corrente baixo nas primeiras 24 horas de ventilação espontânea em pacientes com insuficiência respiratória aguda hipoxêmica e sua associação com dias livres da ventilação mecânica e sobrevida. Métodos: Desenhamos um estudo de coorte multicêntrico, multinacional, com seguimento de 28 dias, que incluirá pacientes com insuficiência respiratória aguda, definida como pressão parcial de oxigênio/fração inspirada de oxigênio &lt; 300mmHg, em transição para ventilação espontânea em unidades de terapia intensiva na América Latina. Resultados: Pretendemos incluir 422 pacientes em 10 países. Os desfechos primários são a prevalência de baixo volume corrente nas primeiras 24 horas de ventilação espontânea e dias livres da ventilação mecânica no dia 28. Os desfechos secundários são mortalidade hospitalar e na unidade de terapia intensiva, incidência de assincronia e retorno à ventilação controlada e sedação. Conclusão: Neste estudo, avaliaremos a prevalência de volume corrente baixo durante a ventilação espontânea e sua associação com os desfechos clínicos, o que pode informar a prática clínica e futuros ensaios clínicos.

Effectiveness of High Flow Nasal Oxygen Therapy in Pneumonia with Acute Hypoxemic Respiratory Failure in Intensive Care Unit, DMCH, Dhaka, Bangladesh

Effectiveness of High Flow Nasal Oxygen Therapy in Pneumonia with Acute Hypoxemic Respiratory Failure in Intensive Care Unit, DMCH, Dhaka, Bangladesh

Adherence to low tidal volume in the transition to spontaneous ventilation in patients with acute respiratory failure in intensive care units in Latin America (SPIRAL): a study protocol.

Patients with acute respiratory failure often require mechanical ventilation to reduce the work of breathing and improve gas exchange; however, this may exacerbate lung injury. Protective ventilation strategies, characterized by low tidal volumes (≤ 8mL/kg of predicted body weight) and limited plateau pressure below 30cmH2O, have shown improved outcomes in patients with acute respiratory distress syndrome. However, in the transition to spontaneous ventilation, it can be challenging to maintain tidal volume within protective levels, and it is unclear whether low tidal volumes during spontaneous ventilation impact patient outcomes. We developed a study protocol to estimate the prevalence of low tidal volume ventilation in the first 24 hours of spontaneous ventilation in patients with hypoxemic acute respiratory failure and its association with ventilator-free days and survival. We designed a multicenter, multinational, cohort study with a 28-day follow-up that will include patients with acute respiratory failure, defined as a partial oxygen pressure/fraction of inspired oxygen ratio < 300mmHg, in transition to spontaneous ventilation in intensive care units in Latin America. We plan to include 422 patients in ten countries. The primary outcomes are the prevalence of low tidal volume in the first 24 hours of spontaneous ventilation and ventilator-free days on day 28. The secondary outcomes are intensive care unit and hospital mortality, incidence of asynchrony and return to controlled ventilation and sedation. In this study, we will assess the prevalence of low tidal volume during spontaneous ventilation and its association with clinical outcomes, which can inform clinical practice and future clinical trials.

Sex difference in the risk of extubation failure in ICUs

BackgroundLittle attention has been paid to potential differences in prognosis between mechanically ventilated males and females in intensive care units (ICUs). We hypothesized that a sex gap in the risk of extubation failure in ICUs may exist.MethodsPost hoc analysis of a large-scale clinical trial including patients at high risk of extubation failure in ICUs, with the aim of assessing the risk of extubation failure according to sex. The primary outcome was reintubation within the 7 days following extubation.ResultsOut of 641 patients, 425 (66%) were males and 216 (34%) were females. Males were more likely to be admitted for cardiac arrest and to have underlying ischemic heart disease whereas females were more likely to be admitted for coma and to have obesity. Whereas the rate of reintubation at 48 h was significantly higher in males than in females (11.0% vs. 6.0%; difference, + 5.0 [95% CI, 0.2 to 9.2]; P = 0.038), the rate of reintubation at day 7 did not significantly differ between males and females (16.7% vs. 11.1%; difference, + 5.6% [95%CI, − 0.3 to 10.8], P = 0.059). Using multivariable logistic regression analysis, male sex was independently associated with reintubation within the 7 days following extubation (adjusted OR 1.70 [95% CI, 1.01 to 2.89]; P = 0.048), even after adjustment on reason for admission, body-mass index, severity score, respiratory rate before extubation, and noninvasive ventilation after extubation.ConclusionIn this post hoc analysis of a clinical trial including a homogeneous subset of patients at high risk of extubation failure, sex was independently associated with reintubation. The role of sex on outcomes should be systematically examined in future studies of critically ill patients.

Association between white blood cell-to-haemoglobin ratio and 30day mortality in heart failure in intensive care unit.

The short-term mortality of heart failure (HF) patients admitted to the intensive care unit (ICU) is reported to be high. This study aims to explore the association between white blood cell-to-haemoglobin ratio (WHR) and 30day mortality from the admission to the ICU. This retrospective cohort study was performed based on the Medical Information Mart for Intensive Care III (MIMIC-III) database (2001-12) and MIMIC-IV database (2008-19). Covariables were selected using the least absolute shrinkage and selection operator regression. Based on the optimal cutoff point selected using the survminer package, WHR was divided into high-ratio group (≥1.6) and low-ratio group (<1.6). The association between WHR and the risk of 30day mortality was explored using univariate and multivariable Cox regression models. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate the prediction performance of WHR. A total of 13702 patients were included. After adjusting the potential covariates, high WHR was associated with a greater risk of 30day mortality compared with low WHR [hazard ratio=1.16, 95% confidence interval (CI): 1.07-1.27, P<0.001]. WHR also showed a good performance for the prediction of risk of 30day mortality (AUC=0.751, 95% CI: 0.746-0.756). WHR was positively associated with and performed well to predict 30day mortality, indicating that WHR may be a reliable index to assess the prognosis of HF patients admitted to the ICU.

Serum Lactate Variability as Predictor of Mortality in Septic Shock: An Experience of Intensive Care Unit of Dhaka Medical College Hospital, Bangladesh

Background: Observation of variability of lactate levels instead of mean lactate level in critically ill patients with sepsis act as more efficient mortality factor. Objective: To determine whether lactate levels measured at different intervals can predict mortality more effectively than that of mean lactate level for septic patients in intensive care unit (ICU). Methods: This cross-sectional study was done in the Department of Anaesthesia, Analgesia, Palliative and Intensive Care Medicine, Dhaka Medical College Hospital, Bangladesh, between July and December of 2019. Purposively selected 147 septic patients with multiple organ failure in Intensive Care Unit were observed prospectively. Serum lactate levels at different intervals were assessed within the first twenty-four hours of recruitment of septic patients. The assigned patients were divided into three lactate variable groups: Group I (mild variable group) – when less than 2 values were not within the target lactate level; Group II (moderate variable group) – when 2-3 values were not within the range; Group III (more variable group) – when more than 3 values were not within the range. Results: The mean age of the study participants was 48.3±12.5years. Among them, 82 (55.78%) were male and 65 (44.22%) were female. Number of survivors and non-survivors in Group I (mild) were 37(84.09%) and 7(15.91%) respectively, while in Group II (moderate) 48(71.64%) and 19(28.36%) respectively and in Group III (more) 13(36.11%) and 23(63.89%) respectively. A highly significant difference (P=0.001) was existed between three blood lactate variability groups with respect to mortality. Logistic regression analysis demonstrated that more lactate variability group had predicted higher mortality rate with a P value of 0.007 and an odds ratio of 16.0. Result is significant. On the other hand, significant effect of moderate lactate variability group on mortality was not found with a P value of 0.665 and an odds ratio of 0.667. Conclusion: The septic patients having more serum lactate variability were reported to have higher mortality rate than that of moderate and less lactate variability in Intensive Care Unit. Our study suggests that serum lactate variability should be included as a future approach to see prognosis and predict mortality in septic patients. Mugda Med Coll J. 2022; 5(2): 71-75

A novel web-based calculator to predict 30-day all-cause in-hospital mortality for 7,202 elderly patients with heart failure in ICUs: a multicenter retrospective cohort study in the United States.

Heart failure (HF) is a significant cause of in-hospital mortality, especially for the elderly admitted to intensive care units (ICUs). This study aimed to develop a web-based calculator to predict 30-day in-hospital mortality for elderly patients with HF in the ICU and found a relationship between risk factors and the predicted probability of death. Data (N = 4450) from the MIMIC-III/IV database were used for model training and internal testing. Data (N = 2,752) from the eICU-CRD database were used for external validation. The Brier score and area under the curve (AUC) were employed for the assessment of the proposed nomogram. Restrictive cubic splines (RCSs) found the cutoff values of variables. The smooth curve showed the relationship between the variables and the predicted probability of death. A total of 7,202 elderly patients with HF were included in the study, of which 1,212 died. Multivariate logistic regression analysis showed that 30-day mortality of HF patients in ICU was significantly associated with heart rate (HR), 24-h urine output (24h UOP), serum calcium, blood urea nitrogen (BUN), NT-proBNP, SpO2, systolic blood pressure (SBP), and temperature (P < 0.01). The AUC and Brier score of the nomogram were 0.71 (0.67, 0.75) and 0.12 (0.11, 0.15) in the testing set and 0.73 (0.70, 0.75), 0.13 (0.12, 0.15), 0.65 (0.62, 0.68), and 0.13 (0.12, 0.13) in the external validation set, respectively. The RCS plot showed that the cutoff values of variables were HR of 96 bmp, 24h UOP of 1.2 L, serum calcium of 8.7 mg/dL, BUN of 30 mg/dL, NT-pro-BNP of 5121 pg/mL, SpO2 of 93%, SBP of 137 mmHg, and a temperature of 36.4°C. Decreased temperature, decreased SpO2, decreased 24h UOP, increased NT-proBNP, increased serum BUN, increased or decreased SBP, fast HR, and increased or decreased serum calcium increase the predicted probability of death. The web-based nomogram developed in this study showed good performance in predicting 30-day in-hospital mortality for elderly HF patients in the ICU.

Comparison of Two Techniques of Peri-Intubation Oxygenation to Minimize the Degree of Desaturation in Patients with Hypoxemic Respiratory Failure in Intensive Care Unit

Introduction: Most common complication encountered while intubating critically ill patients in intensive care unit (ICU) is hypoxemia. Acute physiological abnormalities and poor pulmonary reserve render preoxygenation less effective or insufficient to avoid desaturation even for short duration of apnea in these patients. Measures to oxygenate the patient even during the period of apnea should be considered. Objective: To compare Continuous Positive Airway Pressure (CPAP) administered through nasopharyngeal airway and traditional apneic oxygenation administered through nasal prongs, in reducing the drop in oxygen saturation (SpO2) while intubating critically ill patients in ICU. Methodology: In this randomized controlled study, 50 patients with type I respiratory failure requiring mechanical ventilation, were randomized into 2 groups of 25 each. After 5 min of NIV preoxygenation, in Group NPA – patients received apneic oxygenation through a nasopharyngeal airway connected to ventilator circuit and CPAP of 10 cmH2O Group NC – patients received oxygen via nasal prongs at 15 l/min during intubation. The SpO2 levels at various time intervals of per-intubation period were recorded. Results: Significant difference was observed in degree of desaturation between the 2 groups (2.1 ± 3.5 in group NPA versus 4.24 ± 3.67 in group NC, P value 0.007). The mean tracheal intubation time (44.93 ± 19.66 vs 46.79 ± 18, P value 0.739) and mean intubation difficulty scores (IDS) (1.67 ± 1.39 vs 1.47 ± 1.35, P value 0.464) were comparable in both the groups. Conclusion: The degree of desaturation while intubating hypoxemic patients in ICU is similar with both the techniques of peri-intubation oxygenation, i.e., Oxygen administered though nasal Prongs at 15 L/min and CPAP of 10 cmH2O administered through nasopharyngeal airway. Cinical Trial Registration No. CTRI/2018/09/015747 Registered at www.ctri.gov.in.

Approach to undifferentiated dyspnea in emergency department

Studied cases with acute dyspnea may benefit from quick diagnosis &amp; effective treatment that can save their lives. Emergency patient's history, physical examination, chest radiography, 12-lead electrocardiography, &amp; measurement of brain natriuretic peptide or N-terminal pro-BNP are all techniques for evaluating studied cases who may have acute decompensated heart failure. Chest USG has attracted interest recently since it can be used to diagnose acute respiratory failure in intensive care units. Both cardiac &amp; non-cardiac causes were present in sizable portion of studied cases (twenty eight percent) who presented with dyspnea. Therefore, it is crucial to conduct thorough investigations for all principal reasons for dyspnea in every studied case because a large proportion of patients may have various diseases processes that are accountable for their symptoms.