Hours In Intensive Care Unit Research Articles

Comparing the Clinical Features and Trauma Scores of Trauma Patients Aged Under 65 Years with Those of Patients Aged over 65 Years in the Intensive Care Unit: A Retrospective Study for Last Ten Years.

This retrospective study aimed to compare the clinical characteristics and trauma scores of Intensive Care Unit (ICU) trauma patients 65 years and older with the patients under 65 years old. Trauma patients (n=161) who stayed at least 24 hours in ICU were included. Patients younger than 65 years were included into Group 1 (n=109) and patients aged ≥65 years (n=52) were included into Group 2. Patient characteristics and trauma index scores (GCS; APACHE II score, ISS; TRISS and RTS) at ICU admission were calculated. The patients in Group 2 had more comorbid disease compared with Group 1 (61.5%, 6.4%) (p=0.001). The Trauma-related Injury Severity Score score were higher in Group 1 (49.76±33.75) compared with Group 2 (35.38±34.93) (p=0.006). The APACHE II score were higher in Group 2 (20.08±7.60) compared with Group 1 (17.00±6.90) (p=0.007). The need for invasive mechanical ventilation and tracheostomy were more frequent in Group 2 trauma patients compared with those of patients in Group 1 (92.3%, 73.4%; p=0.003; 26.9%, 8.3%; p=0.002; respectively). The need for transfusion of packed red blood cell suspension (PRBC) was more frequent in Group 2 compared with Group 1 (92.3%, 55.0%; respectively) (p=0.001). The mortality rate was found to be higher in Group 2 compared with Group 1 (48.1%, 19.3%; respectively) (p=0.001). The elderly trauma patients have more comorbid disease, higher scores for APACHE II and lower scores for TRISS, more mechanical ventilation and tracheostomy requirements and higher mortality rate compared with young trauma patients.

Diagnostic value of the Sepsis-3 standard for patients with sepsis: a multi-center prospective, observational clinical study

To explore the value of Sepsis-3 standard in diagnosis of patients with sepsis. Patients who were infected or suspected of infection in intensive care unit (ICU) of six hospitals in Jiangsu Province from September 2017 to August 2018 were enrolled. They were divided into four groups: group A was in accordance with Sepsis-1 and Sepsis-3, group B only met the Sepsis-1 standard, group C only met the Sepsis-3 standard, and both Sepsis-1 and Sepsis-3 standard did not match in group D. The age, gender, underlying disease, diagnosis and source of infection, vital signs within 24 hours of ICU, systemic inflammatory response syndrome (SIRS) score, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation II (APACHE II) score, quick sequential organ failure assessment (qSOFA) score, the length of ICU stay, total hospitalization time, 28-day mortality rate, etc. were recorded. The above collected data were compared and analyzed in groups, and the receiver operating characteristic (ROC) curves of each scoring standard were drawn and calculated. The area under the ROC curve (AUC), and the Youden index of each score was calculated to predict the optimal cut-off value of 28-day mortality in patients with sepsis and its corresponding sensitivity and specificity. A total of 527 patients with infection or suspected infection were enrolled in the study, including 324 patients in group A, 113 patients in group B, 22 patients in group C, 68 patients in group D, and 28-day mortality were 38.9%, 17.7%, 31.8%, and 11.8%, respectively, and there was statistically significant difference among four groups (P < 0.05). The SIRS scores of the A, B, C, D groups were 3 (1), 2 (1), 1 (0), 1 (0), APACHE II scores were 17 (10), 11 (10), 15 (8), 12 (8), qSOFA score were 2 (1), 1 (1), 1 (1), 1 (2), SOFA scores were 8 (6), 1 (0), 7 (4), 1 (0), respectively, there were statistically significant differences among four group (all P < 0.05). Values of SOFA, qSOFA and SIRS scores were evaluated by ROC to predict the value of 28-day mortality. The results showed that AUC and 95% confidence interval of SOFA score was superior to qSOFA score and SIRS score [0.71 (0.66-0.76) vs. 0.59 (0.55-0.64), 0.57 (0.51-0.62), both P < 0.01]. According to the Youden index, the best cut-off values for the 28-day mortality of SOFA, qSOFA and SIRS scores for sepsis were 7, 2 and 2, respectively, and the sensitivity was 69.4%, 60.1%, 53.6%, the specificity was 61.8%, 76.2%, 51.1%, respectively. The Sepsis-3 standard is superior to the Sepsis-1 standard in the diagnosis and prediction of 28-day mortality in patients with sepsis. qSOFA can be used as an early tool for rapid screening of patients with high-risk sepsis in the ICU bedside.

Abstract WP448: Shorter Intensive Care Unit Stay (12 Hours) Post Thrombolysis is Safe and Reduces Length of Stay for Minor Stroke Patients

Background and Purpose: Acute Stroke Patients treated with intravenous tissue-type plasminogen activator (tPA) require intensive care unit (ICU) monitoring for 24 hours post-treatment due to risk of symptomatic intracranial hemorrhage (sICH). This is a costly and resource intensive practice. In this study, we evaluated the safety and efficacy of shorter ICU monitoring for minor stroke patients treated with tPA. Methods: Consecutive patients age &gt;18 years with a diagnosis of ischemic stroke that received tPA only and who had an initial National Institute of Health Stroke Scale (NIHSS) 0-5 between 1/1/2017 and 3/30/2019 were included. Stroke mimics and those who underwent thrombectomy were excluded. Standard practice 24 hour ICU stay prior to 05/15/2018 was compared with 12 hour ICU stay after that date. The primary outcome was length of stay. Secondary outcome measures included sICH, deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days, and modified rankin scale (mRS) at 90 days. Results: Of the 122 patients identified, 77 patients were in the 24-hour protocol and 45 were in 12-hour ICU stay protocol groups. There was significant difference in length of stay for the 24-hour ICU stay protocol (2.8 days) compared with the 12-hour ICU stay protocol (1.8 days) ( P &lt;.001). Compared with the 24-hour ICU stay, the rates of sICH ( p = .65), DVT ( p = NS), PE ( p = NS), pneumonia ( p = 1.00), favorable discharge disposition ( p = .26), 30 day readmission ( p =0.06) and 90 day mRS 0-2 ( p = .37) were not different between the groups. Conclusion: Compared with 24-hour bed rest, 12-hour bed rest after thrombolysis for minor acute ischemic stroke was associated with without any adverse outcomes. A randomized trial is needed to verify these findings.

Effect of Enhanced Recovery After Surgery Protocol on Patients Who Underwent Off-Pump Coronary Artery Bypass Graft

PurposeEnhanced recovery after surgery (ERAS) is an evidence-based perioperative measure to improve outcomes. Although the benefits of ERAS are well proven for other surgeries, little is known about its effect on off-pump coronary artery bypass graft (OPCABG) surgery. Thus, this study aimed to explore the effect of an ERAS protocol in patients who underwent OPCABG surgery. MethodsThis quasi-experimental study included 94 participants (traditional care group = 47 vs ERAS group = 47). An ERAS protocol was established by a multidisciplinary team. Knowledge of coronary artery disease, fasting time, water deprivation time, extubation time of the tracheal tube and pericardial and mediastinal drainage tube, off-bed activity participation rate, length of hospital stay, hours of intensive care unit (ICU) stay, expenses in ICU, incidence rates of ICU delirium and postoperative nausea and vomiting, and the 6-Minute Walk Test on postoperative day 7 were recorded and calculated between the groups. ResultsDemographics, lifestyle, and disease severity showed no significant difference between the two groups (p > .05). The ERAS group patients had improved understanding of coronary artery disease (t = −3.89, p < .01), shorter fasting time (t = 7.98, p < .01), shorter water deprivation time (t = 9.29, p < .01), increased off-bed activity participation (t = 17.67, p < .01), and the improved 6-Minute Walk Test on postoperative day 7 (t = −3.23, p < .01). ConclusionsThe ERAS protocol is safe and effective for patients undergoing OPCABG surgery.

Burnout syndrome among healthcare professionals in intensive care units: a cross-sectional population-based study.

ObjectiveTo assess the prevalence of and factors associated with Burnout syndrome among intensive care unit professionals.MethodsIn this cross-sectional population-based study, a questionnaire assessing sociodemographic, behavioral, and occupational data was administered to 241 nurses and physicians working in 17 public intensive care units in São Luis (MA), Brazil. The Maslach Burnout Inventory - Human Services Survey was used to identify Burnout syndrome based on Maslach’s and Grunfeld’s criteria. The prevalence of each dimension of the syndrome was estimated with a 95% confidence interval. Associations were estimated by the odds ratios via multiple logistic regression analyses (α = 5%).ResultsThe prevalence of Burnout syndrome was 0.41% (0.01 - 2.29) according to Maslach’s criteria and 36.9% (30.82 - 43.36) according to Grunfeld’s criteria. Infant intensive care unit professionals were more likely to develop emotional exhaustion than other intensive care professionals (OR = 3.16). Respondents over the age of 35 were less likely to develop emotional exhaustion (OR = 0.32) and depersonalization (OR = 0.06). Longer working hours in intensive care units were associated with a reduced sense of personal accomplishment (OR = 1.13). Among nurses, males had a lower sense of professional accomplishment, and not exercising regularly was associated with more emotional exhaustion and less depersonalization. Among physicians, working in infant and cardiology intensive care units made them less likely to have a reduced sense of personal accomplishment, and physicians without a postgraduate degree who worked in intensive care units had a higher chance of having a lower sense of personal accomplishment.ConclusionThis study demonstrated the low prevalence of Burnout syndrome. Most of the professionals reported low levels for each dimension of Burnout, including low levels of emotional exhaustion, low levels of depersonalization, and a lower likelihood of having a reduced sense of personal accomplishment. Nurses and physicians have different characteristics associated with Burnout syndrome.

The Effect of Targeted Beta Blocker Use in Trauma Patients Admitted to the Intensive Care Unit

Beta-blockers are used to reduce heart rate (HR) and thereby reduce myocardial oxygen demand. Current guidelines include a recommendation for the use of beta-blockers titrated to a target HR of 60 to 70 beats per minute (bpm) in certain populations; however, the value of this intervention has not yet been studied in the trauma population. Our objective was to determine whether beta-blockers used to titrate heart rate to 60-70 bpm within the first 24 hours of intensive care unit (ICU) admission affect outcome in trauma patients. We retrospectively examined the trauma registry to identify patients admitted to the ICU of an urban level-I trauma center over the course of January to December 2013; medical records were further reviewed to identify those who received treatment with beta-blockers. Data was collected on patient demographics, maximum/minimum HR within 24 hours of admission, achievement of target HR (60-70 bpm), type of beta-blocker administered, length of stay (LOS), injury severity score (ISS), and survival to discharge. Patients were stratified into two groups based upon whether target HR was achieved at least once during the first 24 hours of ICU admission. Statistical analysis was performed using chi-square analysis or t-test as appropriate. A total of 208 patients, 65 females and 143 males with an average age of 59.3 ± 19.3 years, were included. The majority of patients (88.9%) were treated with metoprolol while the rest received atenolol, labetalol, or carvedilol. Eighty-six patients reached target HR on the first day of ICU admission. Heart rate ranged from 48 to 150 bpm; maximum HR was significantly lower in the target HR achieved group (82 ± 2.4 vs 99.9 ± 2.8 bpm, p<0.001). There was no significant difference between the amount of injury sustained by the target HR achieved (ISS 14.2 ± 1.9) and target HR not achieved (ISS 15.9 ± 1.9) groups. Achievement of target HR was associated with a shorter LOS (5.8 ± 1.3 d vs. 10.5 ± 2.3 d, p-value 0.002) and increased likelihood of survival (OR 5.02, 95%CI 1.67-15.2, p=0.004).

Validation of prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among cardiac-, thoracic-, and vascular-surgery patients admitted to a cardiothoracic intensive care unit.

The sepsis-3 criteria have emphasized the value of a change of two or more points on the SOFA, introduced the qSOFA, and removed the systemic inflammatory response syndrome (SIRS) criteria from the sepsis definition. To externally validate and assess the discriminatory capacities of an increase in the SOFA score by two or more points, the presence of two or more SIRS criteria, or a qSOFA score of 2 or more points for outcomes in 5109 patients, the vast majority of whom were postcardiac surgery patients who were admitted to a Cardiothoracic Surgical ICU in Singapore. A retrospective cohort analysis of 5109 patients with an infection-related primary admission diagnosis in the cardiothoracic intensive care unit (CTICU) at the National University Hospital (NUH) in Singapore from 2010 to 2016. The SOFA, qSOFA, and SIRS criteria were applied to the data representing the worst condition within 24 hours of ICU admission. The primary outcome was in-hospital mortality. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC). In 5109 patients, the average mortality of patients with an increase in the SOFA scores of less than 2 points was 3.5% (n = 64), and it was 6% (n = 199) for those with an increase in the SOFA scores of 2 or more points. The mortality of patients with an increase in the qSOFA scores of less than 2 points was 2.6% (n = 7), and it was 5.3% (n = 256) for those with an increase in the qSOFA scores of 2 or more points. The mortality of patients with an increase in the SIRS criteria of less than 2 points was 3.6% (n = 30), and it was 5.4% (n = 233) for those with an increase in the SIRS criteria of 2 or more points. The AUROC of in-hospital mortality of patients with an increase in the SOFA, qSOFA, and SIRS criteria of 2 or more points was 0.96, 0.95, and 0.95, respectively. In adults with suspected infection admitted to the CTICU in NUH, the change in in-hospital mortality between patients with an increase in SOFA scores of less than 2 and those with an increase of 2 or more was 2.5 percentage points. In contrast to other studies, the absolute change in mortality was nearly the same compared to the qSOFA and SIRS criteria, and the qSOFA score had the greatest percentage increase of 104%, compared to 71% for the SOFA score and 50% for the SIRS criteria. Besides, from the perspective of discriminatory capacities, an increase in SOFA scores of 2 or more did not demonstrate significantly greater prognostic accuracy for in-hospital mortality than equivalent increases in qSOFA scores or SIRS criteria. These findings suggest distinctive characteristics of the study population in the CTICU that are different from the general population.

Pathophysiology of Volume Administration in Septic Shock and the Role of the Clinical Pharmacist.

Objective: To review physiological rationale and evidence base surrounding fluid harm to prepare the clinical pharmacist for accountability regarding volume-related outcomes. Data Sources: A PubMed/MEDLINE search was conducted using the following terms: (fluid therapy) AND [(critical care) OR (sepsis)] from 1966 to August 2019 published in English. Study Selection and Data Extraction: A total of 3364 citations were reviewed with only relevant clinical data extracted. Data Synthesis: Although early fluid resuscitation may be a necessary component to decrease mortality in the majority of patients with septic shock admitted to the intensive care unit (ICU), the benefit of continued administration after the first 24 hours is uncertain. Paradoxically, a positive fluid balance secondary to intravenous fluid receipt has been associated with diverse and perpetuating detriment on a multitude of organ systems after the first 24 hours of ICU stay. Continued clinical harm has been demonstrated on patient outcomes such as rates of mortality and length of stay. Despite the growing body of evidence supporting the potential adverse aspects of positive fluid balance, fluid overload remains common during critical care admission. Conclusion: Physiological concerns to overly zealous fluid administration and subsequent volume overload are vast. Relevance to Patient Care and Clinical Practice: Optimization of fluid balance in critically ill patients with sepsis is primed for clinical pharmacy intervention. Critical care pharmacists have the potential to improve patient care by optimizing fluid pharmacotherapy while potentially reducing adverse events, days on mechanical ventilation, and length of ICU stay.

STAR Protocol for Critically Ill Patients in Malaysia: ICU Staff Survey and Human Factor Assessment

Since 2001, various glycemic control (GC) studies have been conducted to reduce dysglycemia in critically ill patients. To prove their effectiveness, each proposed GC approach requires not only patient clinical results, but also users assessments. This paper presents International Islamic University Malaysia Medical Centre intensive care unit (ICU) staff perceptions and assessments of human factors of Stochastic Targeted (STAR) protocol usage based on a Malaysian pilot trial to analyze the users responses to the protocol in the Malaysian set-up. STAR protocol is a model-based and automated GC that accounts for the individual patient s metabolic variability. The ICU staff feedback on STAR trial was based on 13 survey questions. The survey demonstrated that 87.5% of ICU staff agreed that STAR protocol improved patient s outcome, and is user friendly. Human factor assessment quantifies the different interventions recorded from STAR historical and manual bedside records for a total of 31 diabetes mellitus (DM) and non-diabetes mellitus (NDM) patients. During a total of 6168 hours in ICU stays, the percentage of compliance in blood glucose (BG) measurements, insulin infusion, and nutrition administered for DM and NDM cohorts were 97.3%/97.2%, 74.1%/70.3% and 65%/71.2%, respectively. © 2019 Institute of Electronics and Information Engineers. All rights reserved.

Serum vitamin D level variation in SIRS, sepsis and septic shock

Objectives: Vitamin D has potent immunomodulatory effects with the capability of acting as an autocrine and paracrine agent,and inhibits inflammatory signaling. In this study, our aim was to evaluate the relationship between vitamin D levels in systemicinflammatory response syndrome (SIRS), sepsis and, septic shock patients and outcomes.Patients and Methods: A total of 45 patients whose vitamin D levels were measured within the first 48 hours of Intensive Care Unit(ICU) admission and 20 healthy controls were studied prospectively. The patients were grouped as, SIRS (Group-I,n=10), sepsis(Group-II,n=25), septic shock (Group-III,n=10) and healthy subjects (Group-IV,n=20). Serum vitamin D levels were categorized asa deficiency (≤15ng/mL), insufficiency (16-29ng/mL) and sufficiency (≥30ng/mL). Demographic characteristics, Acute Physiologyand Chronic Health Assessment II (APACHE-II) scores, and biochemical parameters were noted.Results: Vitamin D levels were significantly lower in all study groups compared to the control group (p&amp;lt;0.01), but were similar amongthe study groups. The hospital and ICU length of stay (LOS), and biochemical parameters were similar among the study groups. Themortality rates were 40% in Group I, 57 % in Group II, and 80 % in Group III.Conclusion: In our study patients with SIRS, sepsis and septic shock had lower serum 25-OH vitamin D levels compared to thecontrol group. Our results are in line with the literature that supports a relationship between vitamin D deficiency and inflammation.

Primary graft dysfunction after heart transplantation: Outcomes and resource utilization.

A unified definition of primary graft dysfunction (PGD) after heart transplantation was adopted in 2014, with moderate and severe PGD defined as a need for mechanical circulatory support. While risk factors for PGD are well identified, outcomes and resource utilization have not been well-studied. We examined the resource utilization and associated costs with PGD. All adult heart transplantations (2001-2016) from a statewide Society of Thoracic Surgery database were analyzed by dividing them into two groups-with PGD (requiring mechanical circulatory support) and without PGD. Of the 718 heart transplants, 110 (15.3%) patients developed PGD. Prevalence of PGD for the study duration ranged from 3.7% to 22.7% with no significant trend. The most frequently used mechanical circulatory support device was intra-aortic balloon pump (88%), followed by extracorporeal membrane oxygenation (17%), and catheter-based circulatory support devices (3%). There were no significant differences in demographics or preoperative variables between the two groups. Resource utilization such as total intensive care unit hours, ventilation hours, reoperation for bleeding, blood product transfusions, and length of stay were significantly higher in the PGD group. Postoperative complications were also higher in PGD group including operative mortality (31.8% vs 3.8%, P < .0001). The median cost of heart transplantation was significantly higher in the PGD group $229 482 ($126 044-$388 889) vs $101 788 ($72 638-$181 180) P < .0001. Primary graft dysfunction following heart transplantation developed in 15% of patients. Patients with PGD had significantly higher complications, resource utilization, and mortality. Preventive measures to address the development of PGD would reduce resource utilization and improve outcomes.

Risk factors for mortality after subarachnoid hemorrhage: a retrospective observational study

Background and objectivesSubarachnoid hemorrhage is an important cause of morbidity and mortality. The aim of the study was to determine predictors of mortality among patients with subarachnoid hemorrhage hospitalized in an Intensive Care Unit. MethodsThis is a retrospective study of patients with subarachnoid hemorrhage admitted to the Intensive of our institution during a 7 year period (2009-2015). Data were collected from the Intensive Care Unit computerized database and the patients’ chart reviews. ResultsWe included in the study 107 patients with subarachnoid hemorrhage. A ruptured aneurysm was the cause of subarachnoid hemorrhage in 76 (71%) patients. The overall mortality was 40% (43 patients), and was significantly associated with septic shock, midline shift on CT scan, inter-hospital transfer, aspiration pneumonia and hypernatraemia during the first 72 hours of Intensive Care Unit stay. Multivariate analysis of patients with subarachnoid hemorrhage following an aneurysm rupture revealed that mortality was significantly associated with septic shock and hypernatremia during the first 72 hours of Intensive Care Unit stay, while early treatment of aneurysm (clipping or endovascular coiling) within the first 72 hours was identified as a predictor of a good prognosis. ConclusionsTransferred patients with subarachnoid hemorrhage had lower survival rates. Septic shock and hypernatraemia were important complications among critically ill patients with subarachnoid hemorrhage and were associated increased mortality.

Fatores de risco para mortalidade após hemorragia subaracnoidea: estudo observacional retrospectivo

Background and objectivesSubarachnoid haemorrhage is an important cause of morbidity and mortality. The aim of the study was to determine predictors of mortality among patients with subarachnoid hemorrhage hospitalized in an Intensive Care Unit. MethodsThis is a retrospective study of patients with subarachnoid hemorrhage admitted to the Intensive Care Unit of our institution during a 7 year period (2009–2015). Data were collected from the Intensive Care Unit computerized database and the patients’ chart reviews. ResultsWe included in the study 107 patients with subarachnoid haemorrhage. A ruptured aneurysm was the cause of subarachnoid haemorrhage in 76 (71%) patients. The overall mortality was 40% (43 patients), and was significantly associated with septic shock, midline shift on CT scan, inter‐hospital transfer, aspiration pneumonia and hypernatraemia during the first 72 hours of Intensive Care Unit stay. Multivariate analysis of patients with subarachnoid hemorrhage following an aneurysm rupture revealed that mortality was significantly associated with septic shock and hypernatremia during the first 72 hours of Intensive Care Unit stay, while early treatment of aneurysm (clipping or endovascular coiling) within the first 72 hours was identified as a predictor of a good prognosis. ConclusionsTransferred patients with subarachnoid haemorrhage had lower survival rates. Septic shock and hypernatraemia were important complications among critically ill patients with subarachnoid haemorrhage and were associated increased mortality.

Family satisfaction with critical care in the UK: a multicentre cohort study

ObjectiveTo assess family satisfaction with intensive care units (ICUs) in the UK using the Family Satisfaction in the Intensive Care Unit 24-item (FS-ICU-24) questionnaire, and to investigate how characteristics of...

Scoring Systems and Postoperative Outcomes in Pediatric Liver Transplantation

PurposeThe aim of this study is to investigate the effects of risk scores (Pediatric End-stage Liver Disease [PELD], Child-Turcotte-Pugh [CTP], and Pediatric Risk of Mortality [PRISM-III]) of pediatric liver transplant patients on the postoperative period. MethodSeven cadaveric and 45 living donors, totaling 52 pediatric liver transplantation (LT) patients, were reviewed retrospectively. PELD and CTP scores were calculated based on data at hospital admission. PRISM-III score was calculated from data during the first 24 hours of intensive care unit (ICU) admission. Hospital length of stay (LOS), ICU LOS, patients who developed acute kidney injury (AKI), requirement for inotropic-vasopressor therapy, hospital mortality, long-term mortality, duration of mechanical ventilation, metabolic disease, and demographic features were documented.For CTP score, class C was defined as high, and A and B as low. Cutoff values of PELD and PRISM-III scores were detected by using receiver operating characteristic curves. According to these cutoff values, patients were divided into 2 groups as high and low for each score. Documented data was analyzed and compared in groups for each score. ResultsHospital LOS was significantly longer in the high-PELD (P = .01) and high-CTP (P = .01) groups. ICU LOS was significantly longer in the high-PRISM-III group (P = .01). Requirement for inotropic-vasopressor therapy was significantly higher in the high-PELD (P = .04) and high-CTP (P = .04) groups. ConclusionHemodynamic instability and long hospital LOS can be expected in pediatric post-LT patients with high PELD or CTP scores; there is also the risk that AKI maybe higher for high-PELD score patients. Unexpectedly, the PRISM-III score did not have any correlation with the severity of physiological condition and mortality.

Maximum Norepinephrine Dosage Within 24 Hours as an Indicator of Refractory Septic Shock: A Retrospective Study.

The management of refractory septic shock remains a major challenge in critical care and its early indicators are not fully understood. We hypothesized that the maximum norepinephrine dosage within 24 hours of intensive care unit (ICU) admission may be a useful indicator of early mortality in patients with septic shock. In this retrospective single-center observational study, patients with septic shock admitted to the emergency ICU of an academic medical center between April 2011 and March 2017 were included. Individuals with cardiac arrest and those with do-not-resuscitate orders before admission were excluded. We analyzed if the maximum norepinephrine dosage within 24 hours of ICU admission (MD24) was associated with 7-day mortality. Among 152 patients with septic shock, 20 (15%) did not survive by day 7. The receiver operating characteristic curve analysis for predicting 7-day mortality revealed a cutoff of MD24 of 0.6 μg/kg/min (sensitivity 47%, specificity 93%). In the multivariable regression analysis, a higher MD24 was significantly associated with 7-day mortality (odds ratio: 7.20; 95% confidence interval [CI]: 2.02-25.7; P = .002) but not with 30-day mortality. Using the inverse probability of treatment weighting method in a propensity scoring analysis, a higher MD24 was significantly associated with 7-day (hazard ratio [HR]: 8.9; 95% CI: 3.2-25.0; P < .001) and 30-day mortality (HR: 2.7; 95% CI: 1.2-5.8; P = .012). An MD24 ≥0.6 μg/kg/min was significantly associated with 7-day mortality in patients with septic shock and may therefore be a useful indicator of refractory septic shock.

The Epidemiology of Symptomatic Catheter-associated Urinary Tract Infections in the Intensive Care Unit: A 4-year Single Center Retrospective Study.

Catheter-associated urinary tract infection (CAUTI) occurs frequently in critical illness with signifi-cant morbidity, mortality, and additional hospital costs. The epidemiology of symptomatic ward-acquired CAUTI (within 48 hours of intensive care unit [ICU] admission) has not been carefully examined. The objective of our study was to identify the patient characteristics and microbiology of symptomatic CAUTI in critical illness. A 4-year retrospective observational study (2013-2016) was conducted at a single adult ICU with 30 beds in a tertiary hospital in Northeast China. The enrolled patients were over 18 years of age and had been diagnosed as having symptomatic CAUTIs in the ICU from January 2013 to December 2016. The infor-mation of clinicopathological characteristics (such as age, sex, underlying diseases, hospital admission diagnosis, ICU admission source, severity of illness, duration of urinary catheterization, use of antibiotics, duration of ICU stay, and ICU mortality) was recorded in an electronic database by senior clinicians who were blinded to the study purpose and design. Microbiological data were retrieved from the computerized hospital database. Between January 2013 and December 2016, 4115 patients were admitted to the ICU. Ninety-eight symp-tomatic CAUTI cases were enrolled in this study, including 29 patients who had ward-acquired CAUTI and 69 pa-tients who had ICU-acquired CAUTI. Patients with ward-acquired symptomatic CAUTI had significantly shorter overall ICU length of stay and shorter urinary catheterization time, and the overall ICU mortality was significantly higher in patients who had ICU-acquired symptomatic CAUTI. More third-generation cephalosporins and carbap-enems were used prior to CAUTI in the patients with ICU-acquired symptomatic CAUTI. Escherichia coli and Acinetobacter baumannii were the most common bacteria causing ward-acquired and ICU-acquired CAUTI, re-spectively. There were a higher number of cases of non-Candida albicans infections in patients with ICU-acquired symptomatic CAUTI than in patients with ward-acquired symptomatic CAUTI. Clinical characteristics, microbiological characteristics, and prognosis were different between ward-acquired and ICU-acquired symptomatic CAUTI. Patients with ICU-acquired symptomatic CAUTI had higher overall ICU mortality.

Correlation analysis between mechanical power and lung ultrasound score and their evaluation of prognosis in patients with acute respiratory distress syndrome

To investigate the clinical correlations between mechanical power (MP) and lung ultrasound score (LUS), and analyze their evaluation value of prognosis in patients with acute respiratory distress syndrome (ARDS). Patients with moderate to severe ARDS, who underwent invasive mechanical ventilation admitted to intensive care unit (ICU) of the Lianyungang Affiliated Hospital of Xuzhou Medical University from January 2017 to March 2019 were enrolled. The MP and LUS were recorded 0, 24, 48 and 72 hours after ICU admission. The patients were divided into death group and survival group according to the 28-day prognosis. The trends of MP and LUS in the two groups and their differences between groups were analyzed. Then the MP and LUS were analyzed by bivariate correlation analysis, and their correlations with acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), oxygenation index (PaO2/FiO2), and blood lactate (Lac) were also analyzed. The predictive value of MP and LUS 0 hour and 72 hours in ICU for 28-day mortality in patients with moderate to severe ARDS was analyzed by receiver operating characteristic (ROC) curve. At the end, 83 patients were enrolled, with 32 died and 51 survived in 28-day. The Lac level, APACHE II and SOFA in the death group were significantly higher than those in the survival group, while PaO2/FiO2 was significantly lower than the survival group, and the other baseline indicators were not statistically significant between the two groups. As the treatment time increased, the MP and LUS of the survival group showed a significant decrease trend, while the death group showed a significant upward trend. The MP and LUS of the death group 0, 24, 48, 72 hours after ICU admission were significantly higher than those of the survival group [MP (J/min): 20.97±3.34 vs. 17.20±4.71, 21.56±3.48 vs. 16.87±3.85, 22.72±2.97 vs. 16.13±3.52, 25.81±3.46 vs. 15.24±3.78; LUS: 19.17±3.31 vs. 16.27±4.28, 20.28±3.65 vs. 15.27±3.23, 21.53±4.32 vs. 13.63±3.71, 23.94±3.82 vs. 12.53±2.94, all P < 0.05]. There was a significant positive correlation between MP and LUS 0, 24, 48, 72 hours after ICU admission (r value was 0.547, 0.577, 0.754, and 0.783, respectively, all P < 0.01). The MP and LUS at 0 hour of ICU admission were significantly positively correlated with SOFA and PaO2/FiO2 (r value was 0.421, 0.450, and 0.409, 0.536, respectively, all P < 0.01), but no correlation with Lac and APACHE II was found. The ROC curve analysis showed that the MP and LUS at 0 hour and 72 hours had predictive value for the 28-day mortality [the area under the ROC curve (AUC) of MP was 0.836, 0.867; and the AUC of LUS was 0.820, 0.891, all P < 0.01]. There was a significant correlation between MP and LUS in patients with moderate to severe ARDS. The MP and LUS could be used early to evaluate the 28-day prognosis of patients with moderate to severe ARDS.

The use of APACHE II, SOFA, SAPS 3, C-reactive protein/albumin ratio, and lactate to predict mortality of surgical critically ill patients: A retrospective cohort study.

Several prognostic indices have been employed to predict the outcome of surgical critically ill patients. Among them, acute physiology and chronic health evaluation (APACHE) II, sequential organ failure assessment (SOFA) and simplified acute physiology score (SAPS 3) are widely used. It seems that biological markers such as C-reactive protein (CRP), albumin, and blood lactate levels correlate with the degree of inflammation during the immediate postoperative phase and could be used as independent predictors. The objective of this study is to compare the different predictive values of prognostic indices and biological markers in the outcome of 847 surgical patients admitted to the intensive care unit (ICU) in the postoperative phase.The patients were divided into survivors (n = 765, 57.4% males, age 61, interquartile range 51–71) and nonsurvivors (n = 82, 57.3% males, age 70, interquartile range 58–79). APACHE II, APACHE II death probability (DP), SOFA, SAPS 3, SAPS 3 DP, CRP, albumin, and lactate were recorded on ICU admission (first 24 hours). The area under the ROC curve (AUROC) and 95% confidence interval (95% CI) were used to measure the index accuracy to predict mortality.The AUROC and 95% CI for APACHE II, APACHE II DP, SOFA, SAPS 3, SAPS 3 DP, CRP/albumin ratio, CRP, albumin, and lactate were 0.850 (0.824–0.873), 0.855 (0.829–0.878), 0.791 (0.762–0.818), 0.840 (0.813–0.864), 0.840 (0.813–0.864), 0.731 (0.700–0.761), 0.708 (0.676–0.739), 0.697 (0.665–0.728), and 0.601 (0.567–0.634), respectively. The ICU and overall in-hospital mortality were 6.6 and 9.7%, respectively. The APACHE II, APACHE II DP, SAPS 3, SAPS 3 DP, and SOFA scores showed a better performance than CRP/albumin ratio, CRP, albumin, or lactate to predict in-hospital mortality of surgical critically ill patients.Even though all indices were able to discriminate septic from nonseptic patients, only APACHE II, APACHE II DP, SOFA and to a lesser extent SAPS 3, SAPS 3 DP, and blood lactate levels could predict in the first 24-hour ICU admission surgical patients who have survived sepsis.

Quality of care in biopsychosocial complexity. Risks and health care needs of patients with psychiatric comorbity scheduled for elective surgery: The INTERMED self-assessment questionnaire

The predictors and independent outcome association of delirium after cardiac surgery are important and yet poorly characterised.We performed a retrospective observational study of cardiac surgery patients between January 2009 and March 2016. We defined delirium using ICD-10 diagnostic codes. Multivariable analysis was conducted to find independent associations between baseline variables, delirium, and key clinical outcomes.We studied 2,447 study patients (28.7% female, median age was 66 [IQR 57–74] years). Delirium was coded for in 12.9% of patients overall, and in 22.9% of those aged >75 years. Increasing age, Charlson co-morbidity index, admission not from home, peripheral vascular disease, respiratory disease, preoperative atrial fibrillation, duration of cardiopulmonary bypass and nature of surgery were all independent predictors of delirium. Delirium was independently and strongly associated with increased risk of reintubation (OR 8.18 [95% CI 5.24–12.78]), tracheostomy (OR 10.44 [95% CI 5.91–18.45]), and increased length of stay by 113.7 [95% CI 99.7–127.7] ICU hours and 6.95 [95% CI 5.94–7.95] hospital days, but not 30-day mortality (OR 0.78 [95% CI 0.38–1.59]; p = 0.5).Delirium is common in cardiac surgery patients and increases with age. Delirium was the strongest predictor of reintubation, need for tracheostomy, and prolongation of intensive care unit (ICU) and hospital length of stay. Delirium prevention and attenuation are a priority in cardiac surgery patients.