Higher SOFA Score Research Articles

IDENTIFICATION OF RISK FACTORS PREDICTING MORTALITY IN PATIENTS WITH ARDS RELATED TO SEVERE COVID-19

TYPE: Late Breaking Abstract TOPIC: Chest Infections PURPOSE: Acute respiratory distress syndrome (ARDS) is one of the common clinical manifestations of severe COVID19 and it is also responsible for the high ventilators demand in worldwide.The aim of our study was to assess the risk factors predicting mortality in patients with ARDS developing as complication of severe COVID19 and use appropriate treatment approaches for improving clinical outcomes in such patients. METHODS: Our study was retrospective and we collected clinical data of 289 patients with severe COVID19 complicated with ARDS from five COVID19 hospitals ,from 01 August 2021 to 30 December 2021.The clinical characteristics of the survivors ARDS group(168[58.1%])and non-survivors ARDS group(121[41.9%]) of COVID19 patients were clinically,laboratory ,and radiographically compared. RESULTS: Median age of non-survivors with ARDS was older than those with survivors with ARDS(p<0.001),male and BMI >30 were more likely to die.The incidence of consolidation/ground glass opacities ratio (C/GGO) >1 in lung parenchyma,secondary bacterial infection,mechanical ventilation and lack of use dexamethasone before intubation were common findings among non-survivors with ARDS(p<0.002;<0.01;<0.001;and <0.003 ).High SOFA score and low Pa O2/FiO2(P/F) ratio were associated with higher mortality rate among non-survivors with ARDS . Predictors of death in patients with ARDS were:D-dimer (p<0.0004),creatinine(p<0.009),lymphocytes <0.6x109/L(p<0.001),procalcitonin(p<0.008),and BNP(p<0.0003).Among non-survivors with ARDS high PaCO2 and low arterial blood pH were common findings compared to those survive to the end of investigation(p<0.001). CONCLUSIONS: We identified predictors of mortality in patients with ARDS related to severe COVID19.Our findings may be helpful for healthcare providers take appropriate measures and impact to clinical outcomes in patients with severe COVID19 complicated with ARDS. CLINICAL IMPLICATIONS: critical care ohysicians ,nurses,pulmonologists,respiratory therapist DISCLOSURE: No significant relationships. KEYWORD: Severe COVID19.ARDS,RIsk Factors,Predicting ,Mortality

EXPERIENCE OF CLABSI PREVENTION MEASURES IN A MEDICAL ICU IN A TERTIARY CARE HOSPITAL IN A DEVELOPING COUNTRY

TYPE: Abstract TOPIC: Education, Research, and Quality Improvement PURPOSE: To reduce the incidence of CLABSI (central line associated bloodstream infection) in the Intensive care unit (ICU) handling medical patients in a tertiary care setup. METHODS: Baseline data were collected for the first 6 months. Training for doctors, nurses and technicians provided in fixed intervals for implementation of 5 bundles of prevention, especially hand hygiene. RESULTS: There was a significant fall (25.3 Vs 8.1) in CLABSI rate soon after every educational programme conducted. However, it was followed by a rise again. There was no overall improvement in CLABSI rate after the intervention part (18.4 Vs 19.5). However, subgroup analysis showed that the outbreak of flu season in the second part of the year in the intervention phase made the population incomparable, with more ARDS cases in the second half with high SOFA score. CLABSI rate comparison between ARDS population containing months in the first half and the second half was done, which showed 15.5% reduction. Also, there was a significant increase in hand hygiene rate pre and post intervention (p<0.05). CONCLUSIONS: Fall in CLABSI rate in the months soon after the educational programme is evident but it was ill-sustained. Further, overall comparison did not yield significant reduction as the two populations were heterogeneous. However, reduction in CLABSI rate in the ARDS population showed intensive and continuous educational efforts can make significant improvements. CLINICAL IMPLICATIONS: Intensive and continuous teaching programmes can cause significant reduction in CLABSI in resource limited settings which may prove cost effective, when compared to treating resistant infection with costly antibiotics. DISCLOSURE: Nothing to declare. KEYWORD: CLABSI

A screening study for COVID-19-associated pulmonary aspergillosis in critically ill patients during the third wave of the pandemic.

BackgroundCOVID‐19‐associated pulmonary aspergillosis (CAPA) has been reported as an important cause of mortality in critically ill patients with an incidence rate ranging from 5% to 35% during the first and second pandemic waves.ObjectivesWe aimed to evaluate the incidence, risk factors for CAPA by a screening protocol and outcome in the critically ill patients during the third wave of the pandemic.Patients/MethodsThis prospective cohort study was conducted in two intensive care units (ICU) designated for patients with COVID‐19 in a tertiary care university hospital between 18 November 2020 and 24 April 2021. SARS‐CoV‐2 PCR‐positive adult patients admitted to the ICU with respiratory failure were included in the study. Serum and respiratory samples were collected periodically from ICU admission up to CAPA diagnosis, patient discharge or death. ECMM/ISHAM consensus criteria were used to diagnose and classify CAPA cases.ResultsA total of 302 patients were admitted to the two ICUs during the study period, and 213 were included in the study. CAPA was diagnosed in 43 (20.1%) patients (12.2% probable, 7.9% possible). In regression analysis, male sex, higher SOFA scores at ICU admission, invasive mechanical ventilation and longer ICU stay were significantly associated with CAPA development. Overall ICU mortality rate was higher significantly in CAPA group compared to those with no CAPA (67.4% vs 29.4%, p < .001).ConclusionsOne fifth of critically ill patients in COVID‐19 ICUs developed CAPA, and this was associated with a high mortality.

Study of Significance of Serum Lactate Kinetics in Sepsis as Mortality Predictor.

IntroductionSepsis is one of the leading causes of death worldwide. Serum lactate is being used in sepsis for diagnostic and prognostic purposes for years now. In this study, we shed light over a novel use of lactate in form of various clearance parameters to determine mortality in septic patients at the 28th day.Materials and methodsIn our study, 200 patients with sepsis were included using quick sequential organ failure assessment (qSOFA) score and their lactate levels were measured at the time of admission (0 hour) and 24 hours after admission. Lactate clearance parameters (absolute and relative lactate clearance, lactate clearance rate) were calculated. All patients were followed up for a period of 28 days to determine the outcome, and data analysis was done accordingly.Results and conclusionOur study showed that higher SOFA score, qSOFA score, and serum lactate levels were associated with increased 28th-day mortality. Low absolute, relative lactate clearance and lactate clearance rate were also associated with poor outcomes. The best cutoffs to predict poor outcomes were serum lactate level at 24 hours ≥4 mmol/L and relative lactate clearance ≤40.3% with good sensitivity and specificity.How to cite this articleChaudhari M, Agarwal N. Study of Significance of Serum Lactate Kinetics in Sepsis as Mortality Predictor. Indian J Crit Care Med 2022;26(5):591–595.

Evaluating the Impact of Positive Fluid Balance on Mortality and Length of Stay in Septic Shock Patients.

BackgroundSepsis is accountable for major morbidity and mortality in patients with critical illnesses. The present research was undertaken to evaluate the correlation between fluid balance during hospitalizations and patient outcomes in patients with sepsis.MethodsAn observational study was undertaken at the Critical Care Department, Shifa International Hospital, Islamabad, Pakistan between December 2021 to April 2022. The patients included were over the age of 17 years, with a proven diagnosis of infection. These patients either had positive bacterial cultures, suffered from organ failure secondary to sepsis, or had clinically evident signs of infection. Patients who were discharged during the period of study were eliminated from the study population. All patients were informed of the process and signed consent was obtained. Basic demographic information was recorded, which included the existence of any comorbid conditions, organ failure, medication use, or infection history. The severity of critical illness was determined for every single patient along with organ damage. The final patient outcome was recorded as in-hospital mortality.ResultsA total of 307 patients were included in the study with a total of 165 (53.75%) male patients. The overall mortality rate was 39.74%. The mean length of hospitalization was 17.42 ± 8.3 days. A high SOFA score was significantly associated with quartile 4 with a mean score of 14.1 (p < 0.001). Similarly, a significantly higher APACHE score was found in patients in quartile 4 (p < 0.001) thus indicating a relationship between severity of illness and positive fluid balance. Upon further assessment, it was found that the 28th day and 90th day were significantly greater in quartile 4 in comparison to other quartiles. Similarly, the overall length of stays in the hospital and in the ICU were also significantly associated with greater fluid balance (p < 0.001). ConclusionIn our study, it was concluded that monitoring fluid balance in critically ill patients is very important. The highest 28-day and 90-day mortality were seen in patients with the greatest positive fluid balance. However, the cause of high mortality in this cohort could be multifactorial; therefore, the relationship of positive fluid balance with patient outcome remains debatable.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest (OHCA): a four years experience

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Refractory cardiac arrest, defined as the absence of sustained return of spontaneous circulation (ROSC) despite advanced life support (ALS), remains common and is burden by poor outcome. The Extracorporeal Cardiopulmonary Resuscitation (E-CPR) may benefit organ perfusion, potentially improving OHCA outcomes. Purpose The aim of this study was to evaluate outcome of patients with refractory OHCA managed with E-CPR. Methods Single centre prospective observational registry of all patients with OHCA treated with E-CPR from 1 September 2017 to 28 February 2021. The enrolment to E-CPR was defined according to hospital protocol. Results We enrolled 166 patients with OHCA. Out of 59, 39 cases (66,1%) were included in E-CPR program. Prevalence of shockable rhythms was 59%. Survival at discharge from ICU was 10,2% (4 patients; 3 of them discharged with CPC 1-2 and all with ventricular fibrillation at presentation). E-CPR versus patients without refractory arrest have been compared: patients in the E-CPR group were younger (p=0,0002), had lower mean arterial pressure at ROSC and higher SOFA score (p&amp;lt;0,0001). NSE values between survivor (53,8 ± 17,9 mcg/L) and non-survivor (104,8 ± 44,2 mcg/L) at 24 hours were statistically significant (p=0,0669) as well as lactate clearance in the first 48 hours (p=0,001). In the univariate regression model serum lactate at admission (p&amp;lt;0,001; 95% CI 0,87 to 6,83), longer low flow time (p&amp;lt;0,002; 95% CI 0,99 to 1,29) and lower mean arterial pressure (p&amp;lt;0,01; 95% CI 0,99 to 1,29) were associated to mortality. Whereas only lactates (p&amp;lt;0,001; 95% CI 0,092 to 4,56) and low flow time (p&amp;lt;0,001; 95% CI 0,092 to 0,17) retained the association in the multivariate model (figure 1 for ROC curves). Conclusion Mortality rate in OHCA remains unacceptably high. Patients undertaking E-CPR have worsen hemodynamic and clinical parameters at admission, likely to consequence of refractory cardiac arrest. Low-flow time and lactates level are related to higher mortality as expression of worsen metabolic condition related to hypoperfusion state in patients with delayed ROSC.

Evaluation of Risk Factors for Cardiac Complications After Lung Resection

Aim: The aim of this study is to evaluate cardiac complications (CC) and risk factors associated with these complications in patients after lung resection. Methods: Cardiac complications were observed in 136 (11.4%) of 1186 patients who underwent lung resection in a single center between 2017 and 2020. 136 patients who developed complications in the same period and 215 patients who had consecutive operations and did not develop complications were included in the study Results: 287 (81.7%) of the patients were male and the mean age was 58.9 years. There is a statistically significant relationship between cardiac complications after lung resection with geriatric age, male gender, presence of hypertension (HT), presence of lung cancer, neoadjuvant therapy, high SOFA score, chronic obstructive pulmonary disease (COPD), and cerebrovascular accident (CVA). In addition, CVA, EF&lt;60%, neoadjuvant therapy, pneumonectomy, high Sequential Organ Failure Assessment score (SOFA) and intraoperative blood transfusion were found to be independent risk factors for the development of complications. Among the intraoperative factors, pneumonectomy (p&lt;0.001), thoracotomy (p=0.002), intraoperative blood product use (p&lt;0.001) and inotropic use (p&lt;0.001) were correlated with CC. In multiple logistic regression analysis, preoperative thyroid disease (p=0.04), CVA (p=0.001), neoadjuvant therapy (p=0.002), EF&lt;60% (p=0.01), pneumonectomy (p=0.003), intraoperative blood transfusion (p&lt;0.0001) and high SOFA score (p&lt;0.0001) emerged as independent risk factors affecting the development of cardiac complications. Conclusions: There is significant relationship between cardiac complications after lung resection with geriatric age, male sex, HT, lung cancer presence, neoadjuvant therapy, high SOFA score, COPD, CVA presence. In addition, CVA, EF&lt; 60%, neoadjuvant therapy, pneumonectomy and high SOFA score and intraoperative blood transfusion were identified as independent risk factors in the development of complications.

The Impact of Donor Risk Index, Recipients’ and Operative Characteristics on Post Liver Transplant One-Year Graft Failure: A Cohort Analysis

Background and Aims: The donor risk index (DRI) quantifies donor-related characteristics potentially associated with increased risk of early graft failure. We aimed to assess the impact of the DRI, recipient and perioperative factors on post liver transplant (LT) outcomes. Methods: This was a single-center retrospective cohort study including all adult (≥18 years) patients who underwent LT from 01/2019 to 12/2019 at Curry Cabral Hospital, Lisbon, Portugal. Primary endpoint was 1-year graft failure post LT. Associations were studied with logistic regression. Results: A total of 131 cadaveric donor LT procedures were performed in 116 recipients. Recipients’ median (IQR) age was 57 (47–64) years and 101/131 (77.1%) were males. Cirrhosis was the underlying etiology in 95/131 (81.2%) transplants. Based on 8 predefined donors’ characteristics, median (IQR) DRI was 1.96 (1.67–2.16). Following adjustment for MELDNa score pre LT and SOFA score (adjusted odds ratio [aOR], 95% confidence interval [CI] = 0.91 [0.56–1.47]) or lactate (aOR [95% CI] = 2.76 [0.71–10.7]) upon intensive care unit (ICU) admission post LT, DRI was not associated with 1-year graft failure. However, higher SOFA score (aOR [95% CI] = 1.20 [1.05–1.37]) or lactate (aOR [95% CI] = 1.27 [1.10–1.46]) upon ICU admission post LT were independently associated with higher odds of 1-year graft failure. Conclusions: In a recent cohort of patients who underwent LT, DRI, despite being high, was not associated with 1-year graft failure, but SOFA score or lactate upon ICU admission post LT were.

Utilidad de la diferencia venoarterial de PCO2 como predictor de complicaciones en el postoperatorio inmediato del trasplante hepático

ObjectiveTest whether the development of abnormal venous-to arterial CO2 difference (ΔPCO2) during the early phases of postoperative care after a liver transplantation is related to multi-organ dysfunction and outcomes. Materials and methodsProspective cohort study accomplished in a mixed intensive care unit at a university hospital. We included 150 eligible patients after a liver transplantation between 2015 and 2018.Patients were classified in 4predefined groups according to the ΔPCO2 evolution during the first 6h of resuscitation: 1) persistently normal ΔPCO2 (normal at T0 and T6); 2) decreasing ΔPCO2 (high at T0, normal at T6); 3) increasing ΔPCO2 (normal at T0, high at T6); and 4) persistently high ΔPCO2 (high at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities using a log-rank test to evaluate differences between groups. A Spearman-rho was used to test the agreement between cardiac output and ΔPCO2. ResultsThere were no significant differences between the study groups regarding higher SOFA scores at day-3 (P=0.86), Δ-SOFA (P=0.088), as well as global mortality rates (χ2=5.72; P=0.126) and mortality rates at day-30 (χ2=2.23; P=0.5252).A significantly poor inverse agreement between cardiac output and ΔPCO2 was observed (rho de Spearman −0,17; P=0,002) at different points of resuscitation. ConclusionsAfter a liver transplantation, central venous-to-arterial CO2 difference was not associated with survival or postoperative adverse outcomes in a critical care patients population.

Ischemic injury of the upper gastrointestinal tract after out-of-hospital cardiac arrest: a prospective, multicenter study

BackgroundThe consequences of cardiac arrest (CA) on the gastro-intestinal tract are poorly understood. We measured the incidence of ischemic injury in the upper gastro-intestinal tract after Out-of-hospital CA (OHCA) and determined the risk factors for and consequences of gastrointestinal ischemic injury according to its severity.MethodsProspective, non-controlled, multicenter study in nine ICUs in France and Belgium conducted from November 1, 2014 to November 30, 2018. Included patients underwent an esophago-gastro-duodenoscopy 2 to 4 d after OHCA if still intubated and the presence of ischemic lesions of the upper gastro-intestinal tract was determined by a gastroenterologist. Lesions were a priori defined as severe if there was ulceration or necrosis and moderate if there was mucosal edema or erythema. We compared clinical and cardiac arrest characteristics of three groups of patients (no, moderate, and severe lesions) and identified variables associated with gastrointestinal ischemic injury using multivariate regression analysis. We also compared the outcomes (organ failure during ICU stay and neurological status at hospital discharge) of the three groups of patients.ResultsAmong the 214 patients included in the analysis, 121 (57%, 95% CI 50–63%) had an upper gastrointestinal ischemic lesion, most frequently on the fundus. Ischemic lesions were severe in 55/121 (45%) patients. In multivariate regression, higher adrenaline dose during cardiopulmonary resuscitation (OR 1.25 per mg (1.08–1.46)) was independently associated with increased odds of severe upper gastrointestinal ischemic lesions; previous proton pump inhibitor use (OR 0.40 (0.14–1.00)) and serum bicarbonate on day 1 (OR 0.89 (0.81–0.97)) were associated with lower odds of ischemic lesions. Patients with severe lesions had a higher SOFA score during the ICU stay and worse neurological outcome at hospital discharge.ConclusionsMore than half of the patients successfully resuscitated from OHCA had upper gastrointestinal tract ischemic injury. Presence of ischemic lesions was independently associated with the amount of adrenaline used during resuscitation. Patients with severe lesions had higher organ failure scores during the ICU stay and a worse prognosis.Clinical Trial RegistrationNCT02349074.

Serum myoglobin as predictor of acute kidney injury and 90-day mortality in patients with rhabdomyolysis after exertional heatstroke: an over 10-year intensive care survey

Objective Rhabdomyolysis (RM) in exertional heatstroke (EHS) often leads to multiple organ dysfunction including acute kidney injury (AKI). Studies have shown that serum creatine kinase (CK) >1000 U/L as a serological diagnostic criterion for RM does not reflect the risk of AKI or mortality. Methods This longitudinal cohort study included all patients with EHS who were admitted to intensive care unit between January 2008 and June 2019. Serum myoglobin (sMb) was studied as the serological marker of RM and compared with CK. Outcome events were AKI and 90-day mortality. Results A total of 161 patients were enrolled, of whom 52 (32.3%) had sMb ≥1000 ng/mL. Patients with sMb ≥1000 ng/mL had higher SOFA score, higher APACHE II score, lower GCS score, and higher incidence of disseminated intravascular coagulation, acute myocardial injury, acute liver injury, AKI, and 90-day mortality than patients with sMb <1000 ng/mL. Lymphocytes, neutrophils, D-Dimer were risk factors for AKI in patients with sMb ≥1000 ng/mL. Curve fitting showed a curved relationship between sMb and EHS-induced AKI but not CK. sMb ≥1000 ng/mL showed better predictive ability for AKI (area under curve: 0.786). APACHE II, SOFA, and GCS scores were risk factors for 90-day mortality in patients with sMb ≥1000 ng/mL. Conclusion Serum myoglobin is a better predictor of AKI and 90-day mortality than CK in patients with RM after EHS.

Prognostic role of automatic pupillometry in sepsis: a retrospective study.

Sepsis-associated brain dysfunction is a frequent disorder in septic patients and has a multifactorial pathophysiology. Cholinergic pathways and brainstem dysfunction may result in pupillary alterations. The aim of this study was to evaluate whether early assessment of the Neurological Pupil Index (NPiTM) derived from an automated pupillometry could predict mortality in critically ill septic patients. Retrospective cohort study of adult critically ill septic patients admitted to the intensive care unit of a University Hospital; patients with acute or known brain damage were excluded. Patients' severity was assessed by the daily Sequential Organ Failure Assessment Score and the SOFA<inf>max</inf> (i.e., highest SOFA Score during the first five days) was computed. The worst NPi (i.e., lowest value from one eye) was collected daily and then computed over the first five days of assessment. Mortality was assessed at hospital discharge. A total of 75 patients were included over the study period (median age 67 [53-75] years and median SOFA Score at admission 10 [8-12]); 64 (85%) presented septic shock; 48 (64%) died at hospital discharge. The worst NPi during the first five days of sepsis was significantly lower in non-survivors compared to survivors (4.4 [3.6-4.6] vs. 4.5 [4.2-4.7]; P=0.042). The worst NPi was also significantly lower in high severity group (i.e., SOFA<inf>max</inf>≥12) when compared to others (4.4 [3.2- 4.5] vs. 4.5 [4.0-4.7] P=0.01). However, in the multivariate analyses, the NPi value was not independently associated with in-hospital mortality or high SOFA<inf>max</inf>. In this study, no independent prognostic role of NPi was observed in septic patients. Further larger prospective studies are needed to better evaluate the role of automated pupillometry in this setting.

Malnutrition Contributes to Low Lymphocyte Count in Early-Stage Coronavirus Disease-2019.

Background and Aim: Lymphocytes play an important role in fighting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Low total lymphocyte count (TLC), which contributes to poor clinical outcomes, is common in persons with coronavirus disease 2019 (COVID-19). The current explanation for the cause of low TLC is that it is directly related to the invasiveness of SARS-CoV-2, which attacks lymphocytes. We hypothesized that malnutrition contributes to the development of low TLC in early-stage COVID-19.Methods: We prospectively enrolled 101 patients with confirmed COVID-19. On their first day of hospitalization, we collected baseline and laboratory data, including clinical symptoms; the Sequential Organ Failure Assessment, Nutrition Risk Screening 2002 and Subjective Global Assessment were used to assess the malnutrition status of the patients. Multivariable logistic regression was used to identify independent risk factors for low TLC and severe COVID-19.Results: Malnutrition was associated with lower TLC in COVID-19. Fifty-nine (58.4%) of the patients showed low TLC, 41 (40.6%) were at risk for malnutrition, and 18 of them were malnourished. Low TLC was an independent risk factor for severe COVID-19. Compared to patients with normal TLC, those with low TLC more often presented with anorexia, malnutrition, higher SOFA scores (P < 0.05) and comorbidities (diabetes and malignancies). Malnutrition (OR: 3.05, 95% CI: 1.5–6.19, P = 0.006) and SOFA scores (OR: 1.51, 95% CI: 1.04-2.43, P = 0.042) were identified as independent risk factors for low TLC.Conclusions: Malnutrition was common among our patients with early-stage COVID-19, and it contributed to the occurrence of low TLC.

Coagulation Studies Are Not Predictive of Hematological Complications of COVID-19 Infection.

Objectives Thrombotic and bleeding complications are common in COVID-19 disease. In a prospective study, we performed a comprehensive panel of tests to predict the risk of bleeding and thrombosis in patients admitted with hypoxic respiratory failure due to severe COVID-19 infection. Methods We performed a single center (step down and intensive care unit [ICU] at a quaternary care academic hospital) prospective study. Sequentially enrolled adult (≥18 years) patients were admitted with acute hypoxic respiratory failure due to COVID-19 between June 2020 and November 2020. Several laboratory markers of coagulopathy were tested after informed and written consent. Results Thirty-three patients were enrolled. In addition to platelet counts, prothrombin time, and activated partial thromboplastin time, a series of protocol laboratories were collected within 24 hours of admission. These included Protein C, Protein S, Antithrombin III, ADAMTS13, fibrinogen, ferritin, haptoglobin, and peripheral Giemsa smear. Patients were then monitored for the development of hematological (thrombotic and bleeding) events and followed for 30 days after discharge. Twenty-four patients (73%) required ICU admissions. At least one laboratory abnormality was detected in 100% of study patients. Nine patients (27%) suffered from significant hematological events, and four patients had a clinically significant bleeding event requiring transfusion. No significant association was observed between abnormalities of coagulation parameters and the incidence of hematologic events. However, a higher SOFA score (10.89 ± 3.48 vs. 6.92 ± 4.10, p = 0.016) and CKD (5/9 [22.2%] vs. 2/24 [12.5%] p = 0.009) at baseline were associated with the development of hematologic events. 33.3% of patients died at 30 days. Mortality was similar in those with and without hematological events. Reduced ADAMTS13 level was significantly associated with mortality. Conclusion Routine extensive testing of coagulation parameters did not predict the risk of bleeding and thrombosis in COVID-19 patients. Thrombotic and bleeding events in COVID-19 patients are not associated with a higher risk of mortality. Interestingly, renal dysfunction and a high SOFA score were found to be associated with increased risk of hematological events.

Effect of Remdesivir on mortality and length of stay in hospitalized COVID-19 patients: A single center study.

Objectives:To see the difference in mortality among hospitalized COVID-19 patients given Remdesivir (RDV) with those who were not given RDV.Methods:A prospective cohort study was conducted on patients who were admitted to the COVID-19 isolation unit at The Indus Hospital, Korangi Campus Karachi between March and June 2020.Results:Groups were similar in age and gender distribution. RDV group was more hypoxic, had severe ARDS and needed higher Oxygen support compared to non-RDV group (p=0.000). Median SOFA score was 2 in RDV vs 5 in non-RDV (p=0.000). More than moderate COVID pneumonia was found in 92% of the RDV group while 89% of non-RDV group (p value=0.001). Median day of illness to administer Remdesivir was 10. There was no difference in mortality (45.5% in RDV vs 40.4% in non-RDV; p=0.4) between the two groups. Median length of hospital stay was 12 days (IQR=7.5-14.5) in RDV group compared to 10 days (IQR=6-14) in non-RDV group (p=0.009).Conclusion:RDV did not show any difference in in-hospital mortality in our patients. More patients had severe ARDS in the RDV group while patients in the non-RDV group had higher SOFA score and multi-organ failure. Length of stay was longer in patients receiving Remdesivir.

Aminoglycoside or Polymyxin Monotherapy for Treating Complicated Urinary Tract Infections Caused by Extensively Drug-Resistant Pseudomonas aeruginosa: A Propensity Score-Adjusted and Matched Cohort Study.

IntroductionExtensively drug-resistant (XDR) Pseudomonas aeruginosa (PA) infections are difficult to treat. We aimed to compare aminoglycosides or polymyxin monotherapy versus other antibiotic regimens (carbapenems, aztreonam, ceftazidime, cefepime, ceftolozane-tazobactam, or ceftazidime-avibactam) in complicated urinary tract infections (cUTI) caused by XDR-PA.MethodsStudy performed at a tertiary-care hospital from 2010 to 2019. All consecutive adult patients with XDR-PA urine cultures and diagnosed with cUTI were retrospectively reviewed. XDR phenotype was defined according to Magiorakos et al. A propensity score was used as a covariate in multivariate analyses and for matching. Primary outcome was early clinical failure and at end of treatment (EOT). Main secondary outcomes were 30- and 90-day mortality, microbiological clearance, and antibiotic-related side effects.ResultsOf the 465 episodes screened, 101 were included, 48% were treated with aminoglycoside or colistin monotherapy. Most XDR-PA were susceptible to colistin (100%) and amikacin (43%). Patients treated with antibiotic regimens other than aminoglycosides or polymyxin monotherapy were more likely to have hematologic malignancy (p < 0.001), higher SOFA score (p = 0.048), and bacteremia (p = 0.003). In multivariate models adjusted by propensity score, aminoglycoside or colistin monotherapy was not associated with worse outcomes. After propensity score matching, 28 episodes in each treatment group were matched. Adjusted ORs (95% CI) for early clinical failure and at EOT with aminoglycosides or polymyxin monotherapy were 0.53 (0.18–1.58) and 1.29 (0.34–4.83), respectively. Aminoglycoside or colistin monotherapy was not associated with higher 30-day (HR 0.93, 95% CI 0.17–5.08) or 90-day mortality (HR 0.68, 95% CI 0.20–2.31), nor with absence of microbiological clearance (OR 0.72, 95% CI 0.33–1.58). No statistically significant differences were found in terms of nephrotoxicity. Clostridioides difficile infection was observed only in the “other antibiotic regimens” group (n = 6, 11.3%).ConclusionsAminoglycosides or polymyxin monotherapy showed good efficacy and safety profile in treating cUTI caused by XDR-PA. These results may be useful for antibiotic stewardship activities.Electronic Supplementary MaterialThe online version of this article (10.1007/s40121-021-00570-z) contains supplementary material, which is available to authorized users.

Does coexistence of fragmented QRS and cardiovascular disease have the ability to predict the mortality in hospitalized, critically ill patients with COVID-19?

In this study, we aimed to investigate the prognostic accuracy of the presence of fragmented QRS (fQRS) on baseline electrocardiogram on the adverse outcome in critical patients with coronavirus disease 2019 (COVID-19) with cardiovascular disease (CVD). The current study was retrospective designed and included 169 patients who were critically ill with COVID-19 and CVD (mean age of 62±15 years). The patients were grouped into those who died (non-survivor group) and those who survived (survivor group). The non-survivors were older and more often had CVD (p=0.009), hypertension (p=0.046), diabetes (p=0.048), cancer (p=0.023), and chronic renal failure (p=0.001). Although the presence of fQRS on the basal electrocardiogram was more common in patients who died, this was not statistically significant (p=0.059). Furthermore, non-survivors had more frequent the coexistence of CVD and fQRS (p=0.029). In Model 1 multivariate regression analysis, CVD alone was not a predictor of mortality (p=0.078), whereas coexistence of CVD and fQRS was found to be an independent predictor of mortality in Model 2 analysis [hazard ratio (HR): 2.243; p=0.003]. Furthermore, older age (HR: 1.022; p=0.006 and HR: 1.023; p=0.005), cancer (HR: 1.912; p=0.021 and HR: 1.858; p=0.031), high SOFA score (HR: 1.177; p=0.003 and HR: 1.215; p<0.001), and increased CRP level (HR: 1.003; p=0.039 and HR: 1.003; p=0.027) independently predicted the mortality in both multivariate analysis models, respectively. fQRS may be a useful and handy risk-stratification tool for clinical outcomes by identifying high-risk individuals, especially among those with CVD.

The predict value of serum/urocystatin C on acute kidney injury in elderly patients with sepsis.

To evaluate the predict value of serum/urocystatin C in acute kidney injury (AKI) in elderly patients with sepsis. A retrospective study was performed and 80 senile patients with sepsis in ** hospital of China was included. According to the diagnosis of AKI, all patients were divided into non-AKI group and AKI group. The clinical characteristics, laboratory and physiological indicators of the two groups were compared. The receiver operating characteristic curve (ROC) was used to analyze the accuracy of the variables, including serum cystatin C, urocystatin C, and serum creatinine, to predict the occurrence of AKI in patients with sepsis. Of the 80 elderly patients with sepsis in China, 29 patients had AKI. Compared with the non-AKI group, patients in the AKI group had higher APACHE II scores, higher SOFA scores, higher procalcitonin, and lower mean arterial pressure (P<0.05). The levels of serum cystatin C, urocystatin C, and serum creatinine in the AKI group were significantly higher than those in the non-AKI group (P<0.05), while the difference in intensive care unit (ICU) mortality rate between the two groups was not significantly different (P>0.05). The ROC curve showed that the area under the curve of serum cystatin C was 0.893, the area under the curve of urocystatin C was 0.898, and the area under the curve of serum creatinine was 0.652. Serum cystatin and urocystatin could be used to predict the occurrence of AKI in elderly patients with sepsis.

Phenylalanine and COVID-19: Tracking disease severity markers

BackgroundAlthough there are several severity predictors for COVID-19, none are specific. Serum levels of phenylalanine were recently associated with increased inflammation, higher SOFA scores, ICU admission, and mortality rates among non-COVID-19 patients. Here, we investigated the relationship between phenylalanine and inflammatory markers in adults with COVID-19. MethodsWe assessed adults with COVID-19 at hospital admission for clinical and laboratory data. Nuclear magnetic resonance spectroscopy measured serum levels of phenylalanine and other amino acids of its metabolomic pathway. Flow Cytometry measured serum levels of IL-2, IL-4, IL-6, Il-10, TNF-α, and IFN-γ. Linear regression models adjusted for potential confounders assessed the relationship between serum levels of phenylalanine and inflammatory cytokines. ResultsPhenylalanine and tyrosine were significantly lower in mild disease as compared to moderate and severe groups. Linear regression models showed that phenylalanine is independently and positively associated with disease severity regardless of the cytokine analyzed and after adjustment for potential confounders. In addition, mild cases showed consistently lower serum phenylalanine levels within the first ten days from disease onset to hospital admission. ConclusionsPhenylalanine is a marker of disease severity. This association is independent of the time between the onset of symptoms and the magnitude of the inflammatory state.

The Epidemiology of Extremity Threat and Amputation after Vasopressor-Dependent Sepsis.

Rationale: Extremity threat and amputation after sepsis is a well-publicized and devastating event. However, there is a paucity of data about the epidemiology of extremity threat after sepsis onset. Objectives: To estimate the incidence of extremity threat with or without surgical amputation in community sepsis. Methods: Retrospective cohort study of adults with Sepsis-3 hospitalized at 14 academic and community sites from 2013 to 2017. Vasopressor-dependent sepsis was identified by administration of epinephrine, norepinephrine, phenylephrine, vasopressin, or dopamine for more than 1 hour during the 48 hours before to 24 hours after sepsis onset. Outcomes included the incidence of extremity threat, defined as acute onset ischemia, with or without amputation, in the 90 days after sepsis onset. The association between extremity threat, demographics, comorbid conditions, and time-varying sepsis treatments was evaluated using a Cox proportional hazards model. Results: Among 24,365 adults with sepsis, 12,060 (54%) were vasopressor dependent (mean ± standard deviation age, 64 ± 16 years; male, 6,548 [54%]; sequential organ failure assessment [SOFA], 10 ± 4). Of these, 231 (2%) patients had a threatened extremity with 26 undergoing 37 amputations, a risk of 2.2 (95% confidence interval [CI], 1.4-3.2) per 1,000, and 205 not undergoing amputation, a risk of 17.0 (95% CI, 14.8-19.5) per 1,000. Most amputations occurred in lower extremities (95%), a median (interquartile range) of 16 (6-40) days after sepsis onset. Compared with patients with no extremity threat, patients with threat had a higher SOFA score (11 ± 4 vs. 10 ± 4; P < 0.001), serum lactate (4.6 mmol/L [2.4-8.7] vs. 3.1 [1.7-6.0]; P < 0.001), and more bacteremia (n = 37 [37%] vs. n = 2,087 [26%]; P < 0.001) at sepsis onset. Peripheral vascular disease, congestive heart failure, SOFA score, and norepinephrine equivalents were significantly associated with extremity threat. Conclusions: The evaluation of a threatened extremity resulting in surgical amputation occurred in 2 per 1,000 patients with vasopressor-dependent sepsis.