First Day In Intensive Care Unit Research Articles

The condition of the fluid compartments by the method of bioimpedancemetry in victims with a blast injury

BACKGROUND. According to the modern standards, in case of an acute blood loss, the pathogenetic provision of fluid therapy is based on the ROSE/D concept. According to this concept, after the initial emergency restoration of circulating blood volume, the fluid compartments should be optimized with further stabilization of the condition.
 OBJECTIVE. To study the fluid compartments in mine-explosive injuries victims.
 MATERIALS AND METHODS. 28 servicemen aged 20 to 51 years (average age 34.6±10.3 years) who were in the intensive care unit (ICU) with mine-explosive injuries of various localization (chest, abdomen, limbs) were examined. The victims were given fluid therapy in a restrictive mode. The condition of fluid compartments was determined by the method of bioimpedance measurement and calculation methods.
 RESULTS. On the first day of ICU stay, the total amount of water in the body exceeded the norm by 3 %. At the same time, the volume of intracellular water was significantly lower than normal by 22 %. On the second day, the total amount of water in the body normalized, but the indicator of intracellular water increased by 9.5 % of the reference.
 CONCLUSIONS. It is shown that despite the restoration of the circulating blood volume, there is an intracellular fluid deficit, which, even in the conditions of the restrictive fluid therapy, is replaced by a slight compensatory intracellular hyperhydration the next day when the intravascular volume of fluid is normalized.

Admission S100B fails as neuro-marker but is a good predictor for intrahospital mortality in major trauma patients

BackgroundS100 B is an extensively studied neuro-trauma marker, but its specificity and subsequently interpretation in major trauma patients might be limited, since extracerebral injuries are known to increase serum levels. Thus, we evaluated the potential role of S100B in the assessment of severe traumatic brain injury (TBI) in multiple injured patients upon emergency room (ER) admission and the first days of intensive care unit (ICU) stay. MethodsRetrospective study employing trauma registry data derived from a level 1 trauma center. Four cohorts of patients were grouped: isolated TBI (iTBI), polytrauma patients with TBI (PT + TBI), polytrauma patients without TBI (PT-TBI) and patients without polytrauma or TBI (control). S100B-serum levels were assessed immediately after admission in the emergency room and during the subsequent ICU stay. Values were correlated with injury severity score (ISS), Glasgow Coma Score (GCS) and in-hospital mortality. Results780 predominantly male patients (76 %) with a median age of 48 (30–63) and a median ISS of 24 (17–30) were enrolled in the study. Admission S100B correlated with ISS and TBI severity defined by the GCS (both p < 0.0001) but not with head abbreviated injury score (AIS) (p = 0.38). Compared with survivors, non-survivors had significantly higher median S100B levels in the ER (6.14 μg/L vs. 2.06 μg/L; p < 0.0001) and at ICU-day 1 (0.69 μg/L vs. 0.17 μg/L; p < 0.0001). S100B in the ER predicted mortality with an area under curve (AUC) of 0.77 (95 % CI 0,70–0,83, p < 0.0001), vs. 0.86 at ICU-day 1 (95 % CI 0,80–0,91, p < 0.0001). ConclusionIn conclusion, S100B is a valid biomarker for prediction of mortality in major trauma patients with a higher accuracy when assessed at the first day of ICU stay vs. immediately after ER admission. Since S100B did not correlate with pathologic TBI findings in multiple injured patients, it failed as predictive neuro-marker because extracerebral injuries demonstrated a higher influence on admission levels than neurotrauma. Although S100B levels are indicative for injury severity they should be interpreted with caution in polytrauma patients.

Illness severity assessment of older adults in critical illness using machine learning (ELDER-ICU): an international multicentre study with subgroup bias evaluation

Comorbidity, frailty, and decreased cognitive function lead to a higher risk of death in elderly patients (more than 65 years of age) during acute medical events. Early and accurate illness severity assessment can support appropriate decision making for clinicians caring for these patients. We aimed to develop ELDER-ICU, a machine learning model to assess the illness severity of older adults admitted to the intensive care unit (ICU) with cohort-specific calibration and evaluation for potential model bias. In this retrospective, international multicentre study, the ELDER-ICU model was developed using data from 14 US hospitals, and validated in 171 hospitals from the USA and Netherlands. Data were extracted from the Medical Information Mart for Intensive Care database, electronic ICU Collaborative Research Database, and Amsterdam University Medical Centers Database. We used six categories of data as predictors, including demographics and comorbidities, physical frailty, laboratory tests, vital signs, treatments, and urine output. Patient data from the first day of ICU stay were used to predict in-hospital mortality. We used the eXtreme Gradient Boosting algorithm (XGBoost) to develop models and the SHapley Additive exPlanations method to explain model prediction. The trained model was calibrated before internal, external, and temporal validation. The final XGBoost model was compared against three other machine learning algorithms and five clinical scores. We performed subgroup analysis based on age, sex, and race. We assessed the discrimination and calibration of models using the area under receiver operating characteristic (AUROC) and standardised mortality ratio (SMR) with 95% CIs. Using the development dataset (n=50 366) and predictive model building process, the XGBoost algorithm performed the best in all types of validations compared with other machine learning algorithms and clinical scores (internal validation with 5037 patients from 14 US hospitals, AUROC=0·866 [95% CI 0·851-0·880]; external validation in the US population with 20 541 patients from 169 hospitals, AUROC=0·838 [0·829-0·847]; external validation in European population with 2411 patients from one hospital, AUROC=0·833 [0·812-0·853]; temporal validation with 4311 patients from one hospital, AUROC=0·884 [0·869-0·897]). In the external validation set (US population), the median AUROCs of bias evaluations covering eight subgroups were above 0·81, and the overall SMR was 0·99 (0·96-1·03). The top ten risk predictors were the minimum Glasgow Coma Scale score, total urine output, average respiratory rate, mechanical ventilation use, best state of activity, Charlson Comorbidity Index score, geriatric nutritional risk index, code status, age, and maximum blood urea nitrogen. A simplified model containing only the top 20 features (ELDER-ICU-20) had similar predictive performance to the full model. The ELDER-ICU model reliably predicts the risk of in-hospital mortality using routinely collected clinical features. The predictions could inform clinicians about patients who are at elevated risk of deterioration. Prospective validation of this model in clinical practice and a process for continuous performance monitoring and model recalibration are needed. National Institutes of Health, National Natural Science Foundation of China, National Special Health Science Program, Health Science and Technology Plan of Zhejiang Province, Fundamental Research Funds for the Central Universities, Drug Clinical Evaluate Research of Chinese Pharmaceutical Association, and National Key R&D Program of China.

Prediction of Intensive Care Unit Length of Stay in the MIMIC-IV Dataset

Accurately estimating the length of stay (LOS) of patients admitted to the intensive care unit (ICU) in relation to their health status helps healthcare management allocate appropriate resources and better plan for the future. This paper presents predictive models for the LOS of ICU patients from the MIMIC-IV database based on typical demographic and administrative data, as well as early vital signs and laboratory measurements collected on the first day of ICU stay. The goal of this study was to demonstrate a practical, stepwise approach to predicting patient’s LOS in the ICU using machine learning and early available typical clinical data. The results show that this approach significantly improves the performance of models for predicting actual LOS in a pragmatic framework that includes only data with short stays predetermined by a prior classification.

Nursing Workload in Patients With Myocardial Ischemia After Non-cardiac Surgery.

Nursing workload (NWL) in the intensive care unit (ICU) is an essential parameter of patient safety. However,little attention has been dedicated to measuringNWL in ICU about patients surgically treated with myocardial ischemia (MI). Methods:The objectives of this study are to describe and examine the NWL by applying the Nursing Activities Score in patients who underwent non-cardiac surgery and developed MI in the ICU. The statistical significance was set at 0.05. The statistical program SPSS 22.0 was used for the analysis. The mean age was 69.1 years, whereas 32.4% of the patients had MI. Hypertension, diabetes mellitus, and dyslipidemia were the main comorbidities. On the first day in ICU, the NWL was similar in all patients (p = 0.947). In the following days, the NWL was significantly higher in patients with MI (p < 0.001). The NWL was considerably higher in patients with MI who died. The present results are essential for planning and using nursing resources according to the care needs of postoperative patients with MI.

Outcomes and Risk Factors of Critically Ill Patients with Hematological Malignancy. Prospective Single-Centre Observational Study.

Background and Objectives: Oncohematological patients have a high risk of mortality when they need treatment in an intensive care unit (ICU). The aim of our study is to analyze the outcomes of oncohemathological patients admitted to the ICU and their risk factors. Materials and Methods: A prospective single-center observational study was performed with 114 patients from July 2017 to December 2019. Inclusion criteria were transfer to an ICU, hematological malignancy, age >18 years, a central line or arterial line inserted or planned to be inserted, and a signed informed consent form. Univariate and multivariable logistic regression models were used to evaluate the potential risk factors for ICU mortality. Results: ICU mortality was 44.74%. Invasive mechanical ventilation in ICU was used for 55.26% of the patients, and vasoactive drugs were used for 77.19% of patients. Factors independently associated with it were qSOFA score ≥2, increase of SOFA score over the first 48 h, mechanical ventilation on the first day in ICU, need for colistin therapy, lower arterial pH on arrival to ICU. Cut-off value of the noradrenaline dose associated with ICU mortality was 0.21 μg/kg/min with a ROC of 0.9686 (95% CI 0.93–1.00, p < 0.0001). Conclusions: Mortality of oncohematological patients in the ICU is high and it is associated with progression of organ dysfunction over the first 48 h in ICU, invasive mechanical ventilation and need for relatively low dose of noradrenaline. Despite our findings, we do not recommend making decisions regarding treatment limitations for patients who have reached cut-off dose of noradrenaline.

Acute Gastrointestinal Injury and Feeding Intolerance as Prognostic Factors in Critically Ill COVID-19 Patients

BackgroundAlthough acute gastrointestinal injury (AGI) and feeding intolerance (FI) are known independent determinants of worse outcomes and high mortality in intensive care unit (ICU) patients, the incidence of AGI and FI in critically ill COVID-19 patients and their prognostic importance have not been thoroughly studied. MethodsWe reviewed 218 intubated patients at Stony Brook University Hospital and stratified them into three groups based on AGI severity, according to data collected in the first 10 days of ICU course. We used chi-square test to compare categorical variables such as age and sex and two-sample t-test or Mann-Whitney U-tests for continuous variables, including important laboratory values. Cox proportional hazards regression models were utilized to determine whether AGI score was an independent predictor of survival, and multivariable analysis was performed to compare risk factors that were deemed significant in the univariable analysis. We performed Kaplan-Meier survival analysis based on the AGI score and the presence of FI. ResultsThe overall incidence of AGI was 95% (45% AGI I/II, 50% AGI III/IV), and FI incidence was 63%. Patients with AGI III/IV were more likely to have prolonged mechanical ventilation (22 days vs 16 days, P-value <0.002) and higher mortality rate (58% vs 28%, P-value <0.001) compared to patients with AGI 0/I/II. This was confirmed with multivariable analysis which showed that AGI score III/IV was an independent predictor of higher mortality (AGI III/IV vs AGI 0/I/II hazard ratio (HR), 2.68; 95% confidence interval (CI), 1.69–4.25; P-value <0.0001). Kaplan-Meier survival analysis showed that both AGI III/IV and FI (P-value <0.001) were associated with worse outcomes. Patients with AGI III/IV had higher daily and mean D-dimer and CRP levels compared to AGI 0/I/II (P-value <0.0001). ConclusionsThe prevalence of AGI and FI among critically ill COVID-19 patients was high. AGI grades III/IV were associated with higher risk for prolonged mechanical ventilation and mortality compared to AGI 0/I/II, while it also correlated with higher D-dimer and C-reactive protein (CRP) levels. FI was independently associated with higher mortality. The development of high-grade AGI and FI during the first days of ICU stay can serve as prognostic tools to predict outcomes in critically ill COVID-19 patients.

Utility of a prediction model for delirium in intensive care unit patients (PRE-DELIRIC) in mechanically ventilated patients with sepsis.

Delirium frequently develops in patients with sepsis during their intensive care unit (ICU) stay, which is associated with increased morbidity and mortality. A prediction model for delirium in patients in ICU, PRE-DELIRIC, has been utilized in overall ICU patients, but its utility is uncertain among patients with sepsis. This study aims to examine the utility of PRE-DELIRIC to predict delirium in mechanically ventilated patients with sepsis. This is a post hoc analysis of a randomized clinical trial in eight Japanese ICUs, which aimed to evaluate the sedative strategy with/without dexmedetomidine in adult mechanically ventilated patients with sepsis. The Confusion Assessment Method for the ICU was used every day to assess for delirium throughout their ICU stay. We excluded patients who were delirious on the first day of ICU, those who were under sustained coma throughout their ICU stay, and those who stayed in the ICU less than 24h. The discriminative ability of PRE-DELIRIC was evaluated by measuring the area under the receiver operating characteristic curve (AUROC). Of the 201 patients enrolled in the trial, we analyzed 158 patients. The mean age was 69.4±14.0years, and 99 patients (63%) were men. Delirium occurred at least once during the ICU stay of 63 patients (40%). The AUROC of PRE-DELIRIC was 0.60 (95% confidence interval, 0.50-0.69). Subgroup analyses indicated that PRE-DELIRIC was useful in those with Sequential Organ Failure Assessment score >8 with AUROC of 0.65 (95% confidence interval, 0.51-0.77). The PRE-DELIRIC model could not predict delirium in mechanically ventilated patients with sepsis.

Influence of Early versus Late supplemental ParenteraL Nutrition on long-term quality of life in ICU patients after gastrointestinal oncological surgery (hELPLiNe): study protocol for a randomized controlled trial

BackgroundNutrition plays a major role in intensive care unit (ICU) treatment, influencing ICU length of stay and patient’s survival. If preferable enteral nutrition administration is not feasible, ESPEN and ASPEN guidelines recommend initiation of a supplemental parenteral route between the first and seventh day, but exact timing remains elusive. While rapid development in critical care enabled significant reduction in the mortality rate of ICU patients, this improvement also tripled the number of patients going to rehabilitation. Thus, it is quality of life after ICU that has become the subject of interest of clinicians and healthcare policy-makers. A growing body of evidence indicates that protein turnover in the early phase of critical illness may play a crucial role in the preservation of lean body mass. A negative protein balance may lead to muscle wasting that persists weeks and months after ICU stay, resulting in deterioration of physical functioning. Folliwing oncological gastrointestinal tract surgery, patients are threatened with negative protein turnover due to cancer and extensive surgical insult.MethodsThis is a multi-centre, single-blinded, randomised controlled trial. The study population includes patients admitted to ICU units after major oncological gastrointestinal surgery that require supplemental parenteral nutrition. After initiation of enteral nutrition, the intervention group receives remaining daily requirement via supplemental parenteral nutrition on the first day of ICU stay while the control group is not supplemented parenterally until the seventh day of ICU stay while enteral nutrition is gradually increased.Primary endpoint: long-term quality of life measured in the physical component score (PCS) of SF-36 questionnaire at 3 and 6 months after ICU admission.DiscussionTo our knowledge, this is the first trial to investigate the influence of early supplemental parenteral nutrition on long-term quality of life after major oncological gastrointestinal surgery. We assume that, particularly in this population of patients, early supplemental parenteral nutrition may increase the long-term quality of life. The study construction also allows establishment of patients’ PCS SF-36 score prior to surgery and mean change in PCS SF-36 score during the recovery period, which is rarely seen in studies on critically ill patients.Trial registrationClinicalTrials.gov: NCT03699371 registered on 12 October 2018.

Early prediction of acute kidney injury following ICU admission using a multivariate panel of physiological measurements

BackgroundThe development of acute kidney injury (AKI) during an intensive care unit (ICU) admission is associated with increased morbidity and mortality.MethodsOur objective was to develop and validate a data driven multivariable clinical predictive model for early detection of AKI among a large cohort of adult critical care patients. We utilized data form the Medical Information Mart for Intensive Care III (MIMIC-III) for all patients who had a creatinine measured for 3 days following ICU admission and excluded patients with pre-existing condition of Chronic Kidney Disease and Acute Kidney Injury on admission. Data extracted included patient age, gender, ethnicity, creatinine, other vital signs and lab values during the first day of ICU admission, whether the patient was mechanically ventilated during the first day of ICU admission, and the hourly rate of urine output during the first day of ICU admission.ResultsUtilizing the demographics, the clinical data and the laboratory test measurements from Day 1 of ICU admission, we accurately predicted max serum creatinine level during Day 2 and Day 3 with a root mean square error of 0.224 mg/dL. We demonstrated that using machine learning models (multivariate logistic regression, random forest and artificial neural networks) with demographics and physiologic features can predict AKI onset as defined by the current clinical guideline with a competitive AUC (mean AUC 0.783 by our all-feature, logistic-regression model), while previous models aimed at more specific patient cohorts.ConclusionsExperimental results suggest that our model has the potential to assist clinicians in identifying patients at greater risk of new onset of AKI in critical care setting. Prospective trials with independent model training and external validation cohorts are needed to further evaluate the clinical utility of this approach and potentially instituting interventions to decrease the likelihood of developing AKI.

Association between autonomic control indexes and mortality in subjects admitted to intensive care unit

This study checks whether autonomic markers derived from spontaneous fluctuations of heart period (HP) and systolic arterial pressure (SAP) and from their interactions with spontaneous or mechanical respiration (R) are associated with mortality in patients admitted to intensive care unit (ICU). Three-hundred consecutive HP, SAP and R values were recorded during the first day in ICU in 123 patients. Population was divided into survivors (SURVs, n = 83) and non-survivors (NonSURVs, n = 40) according to the outcome. SURVs and NonSURVs were aged- and gender-matched. All subjects underwent modified head-up tilt (MHUT) by tilting the bed back rest segment to 60°. Autonomic control indexes were computed using time-domain, spectral, cross-spectral, complexity, symbolic and causality techniques via univariate, bivariate and conditional approaches. SAP indexes derived from time-domain, model-free complexity and symbolic approaches were associated with the endpoint, while none of HP variability markers was. The association was more powerful during MHUT. Linear cross-spectral and causality indexes were useless to separate SURVs from NonSURVs, while nonlinear bivariate symbolic markers were successful. When indexes were combined with clinical scores, only SAP variance provided complementary information. Cardiovascular control variability indexes, especially when derived after an autonomic challenge such as MHUT, can improve mortality risk stratification in ICU.

Cardiac biomarkers are associated with maximum stage of acute kidney injury in critically ill patients: a prospective analysis

BackgroundThis study aimed to investigate whether cardiac troponin T (cTnT), cardiac troponin I (cTnI) and serum N-terminal pro-brain natriuretic peptide (NT-proBNP) are associated with acute kidney injury (AKI) and need for acute renal replacement therapy (RRT) in adult patients admitted to the intensive care unit (ICU).MethodsWe analysed prospectively collected data for patients admitted to the ICU between June and December 2010 for non-cardiac reasons. The Kidney Disease Improving Global Outcomes creatinine criteria were applied to identify patients with AKI including those who received acute RRT. Severity of illness was determined by the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Serial Organ Failure Assessment (SOFA) score. Regression analyses were performed to assess the association between cTnT, cTnI and NT-proBNP concentrations on the first day of ICU stay, maximum AKI stages and need for acute RRT. Sensitivity analysis was performed in which patients who developed a myocardial infarction during their stay in the ICU were excluded.ResultsOf 138 patients included, 73 (53%) had AKI and 40 (29%) required acute RRT. Patients with AKI were significantly older, more likely to have sepsis and had higher APACHE II and SOFA scores on admission to the ICU. In univariable analysis, cTnT, cTnI and NT-proBNP were significantly higher in those with AKI requiring acute RRT, but after adjustment for baseline differences in severity of illness, cumulative fluid balance and pre-existing comorbidities, only NT-proBNP remained significantly associated with worst stage of AKI and need for RRT. cTnT and cTnI were independently associated with the odds of any AKI but not with need for RRT.In a sensitivity analysis in which patients who had an acute myocardial infarction while in the ICU were excluded, NT-proBNP remained independently associated with AKI and acute RRT.ConclusionsIn critically ill patients admitted to the ICU for non-cardiac reasons, admission NT-proBNP had the strongest independent association with maximum stage of AKI and need for RRT.

Delayed Fever and Neurological Outcome after Cardiac Arrest: A Retrospective Clinical Study.

The aim of this study was to evaluate the association between fever after the first days of ICU stay and neurological outcome after cardiac arrest (CA). We retrospectively analyzed CA patients admitted to intensive care unit (ICU). age ≥18 years, Glasgow Coma Scale score ≤8 at ICU admission and assessment of body core temperature (BCT) using bladder or intravascular probes. ICU length of stay (LOS) <3 days and pregnancy. The primary endpoint was neurological outcome assessed with Cerebral Performance Category (CPC) scale 6 months after CA. One hundred thirty-two patients were analyzed. Fever was present in 105 (79.6%) patients. Variables associated with unfavorable outcome were (1) older age (p < 0.0025); (2) non-shockable cardiac rhythms (p < 0.0001); (3) higher Simplified Acute Physiology Score (SAPS) II (p < 0.0001); (4) pupillary abnormalities at ICU admission (p < 0.018); and (5) elevated degree of maximal BCT (Tmax) during ICU stay (p < 0.046). After multivariate analysis, Tmax maintained a significant relationship with neurological outcome. An increase of 1 °C in Tmax during ICU stay decreased the odds ratio for a favorable outcome by a factor of 31% (p < 0.001). Moreover, we discovered a significant interaction between the day of Tmax (t-Tmax) and Tmax (p = 0.004); the later Tmax occurs, the more deleterious effects are observed on outcome. Fever is frequent after CA, and Tmax in ICU is associated with worsened neurological outcome. This association becomes stronger as the timing of Tmax extends further from the CA.

Increased heart rate on first day in Intensive Care Unit is associated with increased mortality.

Objective:To investigate the association of maximum HR during the first day of intensive care unit (ICU) and mortality.Methods:Data of 850 patients over 45 years of age, who were hospitalized in ICU, was retrospectively analyzed. They were divided into two groups; Group-I, patients with maximum HR<100/min Group-II, patients with maximum HR≥100/min on first day. The groups were compared regarding age, sex, use of beta-blockers, use of inotropic and vasopressor drugs, hemodynamic parameters, anemia, mechanical ventilation, length of hospitalization (ICU and total), mortality (ICU and total), and CHARLSON & APACHE-II scores.Results:The mean age of patients was 63±12 years and 86% were after non-cardiac surgery. Maximum HR was 83±11 in Group-I and 115±14/min in Group-II (p=0.002). Group-II patients had more frequent vasopressor and inotropic drugs usage, (p<0.001), anemia, mechanical ventilation (p<0.005), higher CHARLSON & APACHE-II scores, stayed longer in ICU and hospital, and had higher ICU and hospital mortality compared to group-I (p<0.05). APACHE-II scores and maximum HR<100/min were independent variables predicting ICU mortality in multivariate logistic regression analysis whereas usage of beta-blockers was not.Conclusions:Our study showed that maximum HR less than100/minute during the first day of ICU is associated with decreased mortality in Intensive Care Unit.

Prise en charge nutritionnelle en réanimation : choc septique

Major stress such as severe trauma, infection or postoperative state, is frequently associated with increased catabolism and energy expenditure. These contribute to fat-free mass loss. The increase of energy debt in the first week of intensive care unit (ICU) stay is associated with an increase in infectious complications and length of mechanical ventilation and ICU stay. When oral intake is insufficient to cover nutritional needs after the three first days of ICU stay, enteral nutrition (EN) is the first choice and should be started within 24hours. The volume of daily EN should be gradually increased to reach the target within 48hours (20–25kcal/kg/day). Protein provision must be 1.2–1.5g/kg/day. However, enteral feeding could be poorly tolerated by ICU patients due to impaired gastrointestinal motility. In case of gastroparesis, prokinetics can be administered according to previously established protocol. Nevertheless, the use of supplemental parenteral nutrition (PN) or jejunal EN could be necessary in case of failure or insufficient gastric EN. In the ICU, enteral immunonutrition is not indicated because of the absence of additional benefits. Undernutrition prior to admission is likely to worsen during the ICU stay. In case of preexisting undernutrition, the risk of refeeding syndrome is high. EN must be increased very cautiously under tight monitoring of plasma electrolytes, including phosphates, potassium, sodium, calcium, and magnesium. An electrolyte supplementation is warranted in case of plasma deficiencies, along with vitamins and trace elements. Nutrition support is taking part of the management of the ICU patient, as ventilation and hemodynamics. Specific nutritional monitoring is essential to prevent any risk of over- or undernutrition, and to optimize clinical outcome.

Acute kidney injury enhances outcome prediction ability of sequential organ failure assessment score in critically ill patients.

IntroductionAcute kidney injury (AKI) is a common and serious complication in intensive care unit (ICU) patients and also often part of a multiple organ failure syndrome. The sequential organ failure assessment (SOFA) score is an excellent tool for assessing the extent of organ dysfunction in critically ill patients. This study aimed to evaluate the outcome prediction ability of SOFA and Acute Physiology and Chronic Health Evaluation (APACHE) III score in ICU patients with AKI.MethodsA total of 543 critically ill patients were admitted to the medical ICU of a tertiary-care hospital from July 2007 to June 2008. Demographic, clinical and laboratory variables were prospectively recorded for post hoc analysis as predictors of survival on the first day of ICU admission.ResultsOne hundred and eighty-seven (34.4%) patients presented with AKI on the first day of ICU admission based on the risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification. Major causes of the ICU admissions involved respiratory failure (58%). Overall in-ICU mortality was 37.9% and the hospital mortality was 44.7%. The predictive accuracy for ICU mortality of SOFA (areas under the receiver operating characteristic curves: 0.815±0.032) was as good as APACHE III in the AKI group. However, cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.001) for SOFA score ≤10 vs. ≥11 in these ICU patients with AKI.ConclusionsFor patients coexisting with AKI admitted to ICU, this work recommends application of SOFA by physicians to assess ICU mortality because of its practicality and low cost. A SOFA score of ≥ “11” on ICU day 1 should be considered an indicator of negative short-term outcome.

Clinical study of acute gastrointestinal injury classification in early enteral nutrition in patients under intensive care

To study the feasibility of the acute gastrointestinal injury (AGI) classification standard for evaluation of gastrointestinal function in intensive care unit (ICU) patients, and to discuss its value in administration of early enteral nutrition (EN). A perspective study was conducted. 85 patients with AGI admitted to ICU of Tianjin First Center Hospital from January 2013 to June 2013 were enrolled. EN was conducted after ICU admission or within 12-24 hours after high catabolic state. The patients were divided into four groups according to the AGI classification, i.e. grade I, II, III, and IV, and they were treated according to the treatment procedure for AGI. The primary end points were 7-day rate of intake of standard EN, the degree of disease and nutrition, and their correlation with AGI classification. Secondary endpoint was rate of giving EN within 48 hours. Gastrointestinal dysfunction patients accounted for 49.42% (85/172) of the ICU patients, and number of patients in grade I, II, III, IV were 29, 28, 19, 9 respectively. On the first day of ICU stay, there were no statistical differences in age, acute physiology and chronic health evaluation II (APACHEII) score, serum albumin (ALB) and prealbumin (PA) among four groups, and it was demonstrated that the baseline data were comparable. APACHEII score on the seventh day of ICU stay was significantly lower than that on the first day in grade I, II and III patients (grade I: 20.48±2.45 vs. 22.59±2.06, t=-3.120, P=0.031; grade II: 19.34±1.80 vs. 21.65±2.22, t=-4.316, P=0.012; grade III: 20.63±1.34 vs. 23.31±1.70, t=-5.640, P=0.000), and serum PA was significantly increased (grade I: 24.37±6.54 g/L vs. 10.62±7.24 g/L, t=-4.866, P=0.000; grade II: 19.79±12.48 g/L vs. 11.57±8.94 g/L, t=-2.116, P=0.031; grade III: 19.15±8.43 g/L vs. 13.78±6.59 g/L, t=-3.601, P=0.000). On the seventh day of ICU stay, the APACHEII score was higher in grade IV than that in grade I, II and III patients (22.87±3.31 vs. 20.48±2.45, 19.34±1.80, 20.63±1.34, P<0.05 or P<0.01), and PA was obviously lower in grade IV than that in grade I, II and III patients (14.02±8.70 g/L vs. 24.37±6.54 g/L, 19.79±12.48 g/L, 19.15±8.43 g/L, P<0.05 or P<0.01). There was no statistically significant difference among four groups in respect of serum ALB (F=0.454, P=0.722). The rate of giving EN in 24 hours in grade I, II, III, IV patients was 95.4%, 72.1%, 52.0% and 0, respectively (χ2=8.310, P=0.016), and in 48 hours it was 100.0%, 83.0%, 76.0%, and 0 (χ2=5.470, P=0.025). 7-day standard EN intake rate was 100.0%, 88.7%, 84.0% and 34.0% respectively in grade I, II, III, IV patients (χ2=0.720, P=0.017). Correlation analysis showed that there was a negative correlation between AGI classification and rate of giving EN in 1 day (r=-0.62, P=0.04) and 7-day standard EN intake rate (r=-0.76, P=0.02). AGI classification can be used to estimate the gastrointestinal function of patients with critical illness, and it has a significant correlation with early EN support. An early goal achieving intervention based on the AGI classification can improve the nutritional status and the general state of the patients.

Kinésithérapie chez le patient présentant une altération de l’état de conscience

Initial management of comatose patients aims at maintaining vital functions to assess the etiology of coma and administer any specific treatments if required. Management is multidisciplinary. Caregivers play an important role to prevent and treat intensive care unit (ICU)-acquired complications including skin, bone and joint, muscle, lung, thromboembolic and vascular complications. Prolonged immobilization-related complications may rapidly occur in the comatose patients, requiring a rehabilitation program in the first days of ICU stay. The physiotherapist should be aware of the different etiologies of coma as well as their specific features during the acute phase, especially in case of intracranial hypertension since education of caregivers regarding patient’s specific positioning is mandatory. Additionally, the physiotherapist should adapt treatments to each comatose patient’s specificities, be able to assess consciousness level and develop all the different techniques contributing to the patient’s awakening. Early rehabilitation is mandatory to improve the physical and functional outcome of ICU patients as well as their final quality of life.

Serum Creatinine and Weaning in Patients with Chronic Obstructive Pulmonary Disease: Multicenter Pilot Study

Background: Serum creatinine can provide indirect information on body muscle mass. The role of respiratory muscle is very important during the weaning process in patients with chronic obstructive pulmonary disease (COPD). We aimed to assess whether low creatinine levels are a predictor of unsuccessful weaning or prolonged ventilation in COPD patients receiving mechanical ventilation (MV) in the intensive care unit (ICU). Methods: A multicenter, retrospective cohort study was conducted in three ICUs between July 1 st , 2007 and June 30th, 2008. All consecutive COPD patients receiving MV were enrolled. Patients with acute or chronic renal failure were excluded. Patient demographics, ICU severity score (APACHE II), body mass index (BMI), and serum creatinine and blood urea nitrogen (BUN) levels, were recorded on the first day in ICU, and the first and seventh day of weaning. Successful weaning was defined as successful extubation after the first T-piece trial. Unsuccessful weaning was failed extubation after more than one T-piece trial. Prolonged ventilation was MV duration more than seven days. The chi- square, Fischer's exact test, or t-test (where appropriate) were used to compare the simple weaning group, (SWG, successful weaning) and the prolonged weaning group (PWG, unsuccessful weaning or prolonged ventilation). Results: Eighty-five patients were enrolled (SWG, 36 PWG, 49). No significant difference was found between the groups with respect to age, gender, APACHE II score, and BMI. Patients with low creatinine (less than 0.5 mg/dL) on the first day of ICU, and first day of the weaning trial in SWG and PWG were 4/36, 12/49, and 4/36, 19/49, respectively (p>0.16 and p<0.006). Mortality was detected in only PWG (n=7, 8.2%). Conclusion: Low creatinine levels at the start of weaning trial appear to be a predictor of unsuccessful weaning or prolonged ventilation in COPD patients in the ICU.

Prediction of mortality in intensive care unit cardiac surgical patients☆☆☆

The purpose of this study was to develop a specific postoperative score in intensive care unit (ICU) cardiac surgical patients for the assessment of organ dysfunction and survival. To prove the reliability of the new scoring system, we compared its performance to existing ICU scores. This prospective study consisted of all consecutive adult patients admitted after cardiac surgery to our ICU over a period of 5.5 years. Variables were evaluated using the patients of the first year who stayed in ICU for at least 24h. The reproducibility was then tested in two validation sets using all patients. Performance was assessed with the Hosmer-Lemeshow (HL) goodness-of-fit test and receiver operating characteristic (ROC) curves and compared with the Acute Physiology and Chronic Health Evaluation (APACHE II) and Multiple Organ Dysfunction Score (MODS). The outcome measure was defined as 30-day mortality. A total of 6007 patients were admitted to the ICU after cardiac surgery. Mean HL values for the new score were 5.8 (APACHE II, 11.3; MODS, 9.7) for the construction set, 7.2 (APACHE II, 8.0; MODS, 4.5) for the validation set I and 4.9 for the validation set II. The mean area under the ROC curve was 0.91 (APACHE II, 0.86; MODS, 0.84) for the new score in the construction set, 0.88 (APACHE II, 0.84; MODS, 0.84) in the validation set I and 0.92 in the validation set II. Most of general ICU scoring systems use extensive data collection and focus on the first day of ICU stay. Despite this fact, general scores do not perform well in the prediction of outcome in cardiac surgical patients. Our new 10-variable risk index performs very well, with calibration and discrimination very high, better than general severity systems, and it is an appropriate tool for daily risk stratification in ICU cardiac surgery patients. Thus, it may serve as an expert system for diagnosing organ failure and predicting mortality in ICU cardiac surgical patients.