Time Of ICU Admission Research Articles

P150 Profile of Candidemia in a national level HAI Surveillance Network of India

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMBackground Candida is responsible for roughly 96% of all opportunistic mycoses and is a major cause of bloodstream infections (BSIs). The potential for nosocomial spread of Candidemia infections is a new concern concurrent with the rapid expansion of intensive care facilities for COVID-19 patients. With the pandemic of COVID-19 now moving into 2022, it is understood that critically ill COVID-infected patients in the ICUs are commonly infected with highly resistant bacterial and fungal infections.ObjectiveTo estimate the incidence rates and compare the epidemiology of candidemia in COVID infected and non-infected patients requiring ICU care.MethodologyIn this 2-year retrospective multicentric study, we present the findings on candidemia from the Healthcare-Associated Infections (HAI) surveillance network which includes 40 hospitals across India and with special emphasis on differences in the epidemiology of Candidemia in COVID infected and non-infected patients in the pre-COVID (April 2019 to April 2020) and COVID times (April 2020 to April 2021) across this network. We compared the incidence of candidemia between COVID infected and non-infected patients using Poisson regression analysis. Chi-squared (χ2) test was used to test for differences in variables such as gender and 14-day mortality between the patients and Wilcoxon rank-sum (Mann-Whitney) test was used to compare median between the patients.ResultsA total of 628 patients with candidemia were screened from HAI Surveillance Database where 68 patients are COVID infected and 560 non-infected patients from both pre-COVID and COVID periods. Incidence of Candida-associated BSI increased significantly from 1.47 (95% CI, 1.35-1.60) to 3.08 (95% CI, 2.38-3.92) in non-infected and COVID-infected patients respectively, while in CLABSI the rates increased from 2.62 (95% CI, 2.34-2.92) in non-infected to 5.99 (95% CI, 4.30-8.12) in COVID-infected patients. COVID infected patients in the age group (>60 years) were significantly more prone to candidemia compared to non-infected patients. During the COVID period, the maximum time for candidemia to develop (from the time of ICU admission) in COVID-infected patients was shorter (<65 days) than in non-infected patients (>90 days).ConclusionWe observed an increased incidence of candidemia in hospitalized patients during the COVID period compared with the same during the pre-COVID period.

Association between ICU admission during off-hours and in-hospital mortality: a multicenter registry in Japan

BackgroundThe effect of ICU admission time on patient outcomes has been shown to be controversial in several studies from a number of countries. The imbalance between ICU staffing and medical resources during off-hours possibly influences the outcome for critically ill or injured patients. Here, we aimed to evaluate the association between ICU admission during off-hours and in-hospital mortality in Japan.MethodsThis study was an observational study using a multicenter registry (Japanese Intensive care PAtient Database). From the registry, we enrolled adult patients admitted to ICUs from April 2015 to March 2019. Patients with elective surgery, readmission to ICUs, or ICU admissions only for medical procedures were excluded. We compared in-hospital mortalities between ICU patients admitted during off-hours and office-hours, using a multilevel logistic regression model which allows for the random effect of each hospital.ResultsA total of 28,200 patients were enrolled with a median age of 71 years (interquartile range [IQR], 59 to 80). The median APACHE II score was 18 (IQR, 13 to 24) with no significant difference between patients admitted during off-hours and those admitted during office-hours. The in-hospital mortality was 3399/20,403 (16.7%) when admitted during off-hours and 1604/7797 (20.6%) when admitted during office-hours. Thus, off-hours ICU admission was associated with lower in-hospital mortality (adjusted odds ratio 0.91, [95% confidence interval, 0.84–0.99]).ConclusionsICU admissions during off-hours were associated with lower in-hospital mortality in Japan. These results were against our expectations and raised some concerns for a possible imbalance between ICU staffing and workload during office-hours. Further studies with a sufficient dataset required for comparing with other countries are warranted in the future.

Value of Rox Index to Predict Intubation and Intensive Care Unit Outcome in Patients with Respiratory Failure.

Recent literature suggests that the respiratory rate oxygenation (ROX) index may be a useful parameter in predicting intubation indication in hypoxemic patients. In this study, we evaluated the accuracy of the ROX index in predicting intubation, length of stay in the ICU, and mortality in ICU patients with hypoxemic respiratory failure with and without hypercapnia. Single-centre retrospective cohort study of 290 patients, with a preliminary diagnosis of respiratory failure, who were treated with low flow oxygen systems. Demographics, medical history, clinical, laboratory, treatment, and prognostic data were obtained from the electronic records of the hospital. The ROX index was calculated at the time of ICU admission. Thirty-seven percent of non-hypercapnic and 69% of hypercapnic patients were intubated (p:0.005). In hypercapnic patients, ROX: 6.9 had highest sensitivity (81%) and specificity (65%) values for intubation (p:0.005). In non-hypercapnic patients, ROX: 6.2 had the highest sensitivity (81%) and specificity (40%) values. While 11% of hypercapnic patients and 30% of non-hypercapnic patients were died (p:0.05), 22% of hypercapnic patients and 33% of non-hypercapnic patients stayed in the ICU longer than 14 days (p:0.044). The highest sensitivity and specificity values were found for mortality in hypercapnic patients; for ROX value of 5.94 (sensitivity:86%, specificity:61%) and for ICU stay longer than 14 days; for ROX value of 7.4 (sensitivity:71%, specificity:68%). Results of our study suggest that ROX index calculated during ICU admission can be helpful in predicting intubation indication and length of ICU stay in patients with respiratory failure and hypercapnia may influence the cutoff values.

Use of peripherally inserted central catheters with a dedicated vascular access specialists team versus centrally inserted central catheters in the management of septic shock patients in the ICU.

Peripherally inserted central catheters (PICCs) are increasingly recognized as an alternative to centrally inserted central catheters (CICCs) in critical care, yet the data regarding the safety and feasibility of this choice in septic shock management is growing but still lacking. In this study, we aimed to determine the feasibility, safety, and impact on outcomes of using dedicated vascular access specialist (VAS) teams to insert PICCs versus CICCs on patients admitted to the ICU with septic shock. Retrospective cohort study. Mayo Clinic Rochester Medical ICU and Mayo Clinic Arizona Multidisciplinary ICU from 2013 to 2016. All adult patients hospitalized with diagnosis of septic shock excluding patients who declined authorization for review of their medical records, mixed shock states, and readmissions. None. Comprehensive data regarding septic shock diagnosis and resuscitation were abstracted from electronic medical records. A total of 562 patients with septic shock were included in the study; 215 patients were resuscitated utilizing a PICC and 347 were resuscitated using a CICC. On univariate analysis, the time to central line insertion and time to vasopressor initiation were found to be reduced in those who received PICC at time of ICU admission versus CICC. Other favorable outcomes were also observed in those who received PICC versus CICC including shorter ICU length of stay and lower unadjusted hospital mortality. A multivariable analysis for hospital mortality showed that after adjusting for important covariates, neither the time to central line insertion nor the time to vasopressor initiation was associated with a lower hospital mortality. Across two tertiary referral centers within the same enterprise, use of a dedicated VAS team for insertion of PICCs for initial resuscitation in patients with septic shock was feasible and associated with shorter time to central venous access and initiation of vasopressors; however, adjusted hospital mortality was not different between the two groups.

Survival analysis based on body mass index in patients with Covid-19 admitted to the intensive care unit of Amir Al-Momenin Hospital in Arak – 2021

IntroductionThe potential risk of obesity on the severity of COVID-19 has been proposed. The main purpose of this study was to investigate the effect of BMI on the survival rate of COVID-19 patients admitted to the ICU.Methods & materialsPatients with COVID-19 admitted to ICU were included. Gender, height, weight, BMI, age, underlying disease status, prescribed drugs and nutritional supplements, and clinical and laboratory parameters at the beginning of admission were recorded. Death or discharge from the ICU and the days elapsed to these events were also reviewed and recorded. Data analysis was performed using the Cox regression model.Resultsassessing 193 patients showed that BMI was not related to the survival rate even after adjusting for other potential confounding variables. It was shown that arterial oxygen saturation and taking Famotidine were the significant factors determining the time to event in these patients.ConclusionThe BMI at the time of ICU admission has no effect on survival rate and time to event in COVID-19 infected patients admitted to ICU.

Eosinophil count: a predictor of in-hospital mortality in a cohort of cirrhosis patients with sepsis

BackgroundDeclining eosinophil count has recently been associated with sepsis. Thus, absolute eosinophil count (AEC) can be used as a marker of the severity of sepsis, which helps in the early identification of high-risk patients, and better management can be offered to such patients. The aim of this study was to assess whether AEC at the time of ICU admission can be used as a predictor of in-hospital mortality in cirrhotics with sepsis.ResultsThis was a retrospective study which was conducted in 105 cirrhotic patients admitted with sepsis in the Department of Gastroenterology, Medical College Trivandrum, from May 2014 to October 2014. Every consecutive patient with cirrhosis and sepsis (defined as systemic inflammatory response syndrome (SIRS) and the presence of infections) admitted to the ICU/high dependency unit was recruited for the study. Among the various parameters analyzed, model for end-stage liver disease (MELD) score, Child-Pugh Turcot (CTP) score, albumin levels, total count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), alanine aminotransferase (ALT), bilirubin, creatinine, urea, and absolute eosinophil count were statistically significant in predicting in-hospital mortality. The AUROC of AEC was plotted and found to be 0.881, which was better than other parameters for predicting in-hospital mortality. The cutoff of AEC by Youden’s index was 110 cells/cumm (sensitivity 91.3%, specificity 89%, positive predictive value 87.5%, and negative predictive value 93%) to predict in-hospital mortality. The AUROC of MELD was 0.78 with a cutoff of > 24 (sensitivity 89%, specificity 74.6%, positive predictive value 73%, and negative predictive value 89%) to predict the mortality. The odds ratio for predicting mortality was highest for absolute eosinophil count (92.75) followed by MELD (24.57), total count (20.475), CTP (10), and the presence of SIRS (9.08).ConclusionIn critically ill cirrhosis patients with sepsis, AEC < 110 cells/cumm can predict in-hospital mortality.

Improving Post-Injury Care: Key Family Caregiver Perspectives of Critical Illness After Injury.

BACKGROUND:There is little research about how caregiver experiences evolve from ICU admission to patient recovery, especially among caregivers for patients who have traumatic injuries. In this study, we characterize diverse caregiver experiences during and after ICU admission for injury.METHODS:This prospective observational study is based in a level 1 trauma center in Philadelphia, Pennsylvania. Longitudinal interviews among caregivers of patients who required ICU admission for traumatic injury were conducted from the time of ICU admission to 12 months after hospital discharge. Transcripts were analyzed using a qualitative descriptive approach.RESULTS:Sixty-five interviews were conducted with 19 caregivers. The interview results converged on four areas: experiences in the ICU, the aftermath of violent traumatic injury, caregiver responsibilities, and care in the context of the wider family. In the ICU, caregivers contended with worry and uncertainty, and they often hid these feelings. Many felt that they always needed to be at the bedside, leading to stress and exhaustion. Caregivers had difficulty communicating with their loved ones, and communication itself sometimes became a source of conflict. Over time, caregivers were burdened by many managerial responsibilities. In addition, violent traumatic injury caused an overlay of concern for patients’ safety. The need to plan for recovery caused caregivers to make substantial sacrifices. As a result of these difficult experiences, some caregivers and patients drew closer together, while others were divided by conflict.CONCLUSIONS:Illness after traumatic injury may be devastating for caregivers, disrupting emotional wellbeing and other aspects of life. Caregivers are variably prepared for the challenges of ICU care and caregiving through convalescence and require robust support during and after ICU admission to enable effective communication, resource access, and an ongoing relationship with the healthcare team.

Soluble neprilysin and survival in critically ill patients

Abstract Funding Acknowledgements Type of funding sources: None. Background Critically ill patients admitted to an intensive care unit (ICU) exhibit a high mortality rate irrespective of the initial cause of hospitalization. Neprilysin, a neutral endopeptidase degrading an array of vasoactive peptides became a drug target within the treatment of heart failure with reduced ejection fraction.The aim of this study was to analyze whether circulating levels of neprilysin at ICU admission are associated with 30-day mortality. Methods In this single-center prospective observational study, 222 consecutive patients admitted to a tertiary ICU at a university hospital were included. Blood was drawn at admission and soluble neprilysin levels were measured using ELISA. Results In the total cohort, Soluble neprilysin levels did not differ according to survival status after 30 days as well as type of admission. However, in patients after surgery or heart valve intervention, 30-day survivors exhibited significantly lower circulating neprilysin levels as compared to those who died within 30 days (660.2, IQR: 156.4 – 2512.5 pg/ml versus 6532.6, IQR: 1840.1 – 10000.0 pg/ml; p=0.02). Soluble neprilysin predicted mortality independently from age, gender, and commonly used scores of risk-prediction (EuroSCORE II, STS-score, and SAPS II score). Additionally, soluble neprilysin was markedly elevated in patients with sepsis and septic shock (p&amp;lt;0.05). Conclusion At the time of ICU-admission, circulating levels of neprilysin independently predicted 30-day mortality in patients following cardiac surgery or heart valve intervention, but not in critically ill medical patients. Furthermore, patients suffering from sepsis and septic shock displayed significantly increased circulating neprilysin levels.

Harnessing the Data Universe to Understand and Reduce Clinical Deterioration in Children.

Harnessing the Data Universe to Understand and Reduce Clinical Deterioration in Children.

Serum IL-17 levels are higher in critically ill patients with AKI and associated with worse outcomes

BackgroundInterleukin-17 (IL-17) antagonism in rats reduces the severity and progression of AKI. IL-17-producing circulating T helper-17 (TH17) cells is increased in critically ill patients with AKI indicating that this pathway is also activated in humans. We aim to compare serum IL-17A levels in critically ill patients with versus without AKI and to examine their relationship with mortality and major adverse kidney events (MAKE).MethodsMulticenter, prospective study of ICU patients with AKI stage 2 or 3 and without AKI. Samples were collected at 24–48 h after AKI diagnosis or ICU admission (in those without AKI) [timepoint 1, T1] and 5–7 days later [timepoint 2, T2]. MAKE was defined as the composite of death, dependence on kidney replacement therapy or a reduction in eGFR of ≥ 30% from baseline up to 90 days following hospital discharge.ResultsA total of 299 patients were evaluated. Patients in the highest IL-17A tertile (versus lower tertiles) at T1 had higher acuity of illness and comorbidity scores. Patients with AKI had higher levels of IL-17A than those without AKI: T1 1918.6 fg/ml (692.0–5860.9) versus 623.1 fg/ml (331.7–1503.4), p < 0.001; T2 2167.7 fg/ml (839.9–4618.9) versus 1193.5 fg/ml (523.8–2198.7), p = 0.006. Every onefold higher serum IL-17A at T1 was independently associated with increased risk of hospital mortality (aOR 1.35, 95% CI: 1.06–1.73) and MAKE (aOR 1.26, 95% CI: 1.02–1.55). The highest tertile of IL-17A (vs. the lowest tertile) was also independently associated with higher risk of MAKE (aOR 3.03, 95% CI: 1.34–6.87). There was no effect modification of these associations by AKI status. IL-17A levels remained significantly elevated at T2 in patients that died or developed MAKE.ConclusionsSerum IL-17A levels measured by the time of AKI diagnosis or ICU admission were differentially elevated in critically ill patients with AKI when compared to those without AKI and were independently associated with hospital mortality and MAKE.

Persistently elevated complement alternative pathway biomarkers in COVID-19 correlate with hypoxemia and predict in-hospital mortality.

Mechanisms underlying the SARS-CoV-2-triggered hyperacute thrombo-inflammatory response that causes multi-organ damage in coronavirus disease 2019 (COVID-19) are poorly understood. Several lines of evidence implicate overactivation of complement. To delineate the involvement of complement in COVID-19, we prospectively studied 25 ICU-hospitalized patients for up to 21 days. Complement biomarkers in patient sera and healthy controls were quantified by enzyme-linked immunosorbent assays. Correlations with respiratory function and mortality were analyzed. Activation of complement via the classical/lectin pathways was variably increased. Strikingly, all patients had increased activation of the alternative pathway (AP) with elevated levels of activation fragments, Ba and Bb. This was associated with a reduction of the AP negative regulator, factor (F) H. Correspondingly, terminal pathway biomarkers of complement activation, C5a and sC5b-9, were significantly elevated in all COVID-19 patient sera. C5a and AP constituents Ba and Bb, were significantly associated with hypoxemia. Ba and FD at the time of ICU admission were strong independent predictors of mortality in the following 30 days. Levels of all complement activation markers were sustained throughout the patients’ ICU stays, contrasting with the varying serum levels of IL-6, C-reactive protein, and ferritin. Severely ill COVID-19 patients have increased and persistent activation of complement, mediated strongly via the AP. Complement activation biomarkers may be valuable measures of severity of lung disease and the risk of mortality. Large-scale studies will reveal the relevance of these findings to thrombo-inflammation in acute and post-acute COVID-19.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00430-021-00725-2.

Evaluation of Albumin Kinetics in Critically Ill Patients With Coronavirus Disease 2019 Compared to Those With Sepsis-Induced Acute Respiratory Distress Syndrome.

This report aims to characterize the kinetics of serum albumin in critically ill patients with coronavirus disease 2019 compared with critically ill patients with sepsis-induced acute respiratory distress syndrome. Retrospective analysis. We analyzed two critically ill cohorts, one with coronavirus disease 2019 and another with sepsis-induced acute respiratory distress syndrome, treated in the New York Presbyterian Hospital-Weill Cornell Medical Center. Adult patients in the coronavirus disease 2019 cohort, diagnosed through reverse transcriptase-polymerase chain reaction assays performed on nasopharyngeal swabs, were admitted from March 3, 2020, to July 10, 2020. Adult patients in the sepsis-induced acute respiratory distress syndrome cohort, defined by Sepsis III criteria receipt of invasive mechanical ventilation and a Pao2/Fio2 ratio less than 300 were admitted from December 12, 2006, to February 26, 2019. None. We evaluated serial serum albumin levels within 30 days after ICU admission in each cohort. We then examined the albumin progression trajectories, aligned at ICU admission time to test the relationship at a similar point in disease progression, in survivors and nonsurvivors. Albumin trajectory in all critically ill coronavirus disease 2019 patients show two distinct phases: phase I (deterioration) showing rapid albumin loss and phase II (recovery) showing albumin stabilization or improvement. Meanwhile, albumin recovery predicted clinical improvement in critical coronavirus disease 2019. In addition, we found a deterioration and recovery trends in survivors in the sepsis-induced acute respiratory distress syndrome cohort but did not find such two-phase trend in nonsurvivors. The changes in albumin associated with coronavirus disease 2019 associated respiratory failure are transient compared with sepsis-associated acute respiratory distress syndrome and highlight the potential for recovery following a protracted course of severe coronavirus disease 2019.

Thoracic skeletal muscle quantification using computed tomography and prognosis of elderly ICU patients

In elderly ICU patients, the prevalence of skeletal muscle loss is high. Longitudinal effect of thoracic muscles, especially in elderly ICU patients, are unclear although skeletal muscle loss is related with the short- and long-term outcomes. This study aimed to evaluate whether pectoralis muscle mass loss could be a predictor of prognosis in elderly ICU patients. We retrospectively evaluated 190 elderly (age > 70 years) patients admitted to the ICU. We measured the cross-sectional area (CSA) of the pectoralis muscle (PMCSA) at the fourth vertebral region. CT scans within two days before ICU admission were used for analysis. Mortality, prolonged mechanical ventilation, and longitudinal changes in Sequential Organ Failure Assessment (SOFA) scores were examined. PMCSA below median was significantly related with prolonged ventilation (odds ratio 2.92) and a higher SOFA scores during the ICU stay (estimated mean = 0.94). PMCSA below median was a significant risk for hospital mortality (hazards ratio 2.06). In elderly ICU patients, a low ICU admission PMCSA was associated with prolonged ventilation, higher SOFA score during the ICU stay, and higher mortality. Adding thoracic skeletal muscle CSA at the time of ICU admission into consideration in deciding the therapeutic intensity in elderly ICU patients may help in making medical decisions.

The Prognostic Value of Cardiac Biomarkers and Echocardiography in Critical COVID-19.

Background: Early risk stratification is crucial in critically ill COVID-19 patients. Myocardial injury is associated with worse outcome. This study aimed to evaluate cardiac biomarkers and echocardiographic findings in critically ill COVID-19 patients and to assess their association with 30-day mortality in comparison to other biomarkers, risk factors and clinical severity scores.Methods: Prospective, single-center, cohort study in patients with PCR-confirmed, critical COVID-19. Laboratory assessment included high sensitive troponin T (hs-cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) on admission to ICU: a hs-cTnT ≥ 14 pg/mL and a NT-proBNP ≥ 450 pg/mL were considered as elevated. Transthoracic echocardiographic evaluation was performed within the first 48 h of ICU admission. The primary outcome was 30-day all-cause mortality. Predictive markers for mortality were assessed by ROC analysis and cut-off values by the Youden Index.Results: A total of 100 patients were included. The median age was 63.5 years, the population was predominantly male (66%). At the time of ICU admission, 47% of patients had elevated hs-cTnT and 39% had elevated NT-proBNP. Left ventricular ejection fraction was below 50% in 19.1%. Elevated cardiac biomarkers (hs-cTnT P-value < 0.001, NT-proBNP P-value = 0.001) and impaired left ventricular function (P-value = 0.011) were significantly associated with mortality, while other biomarkers (D-dimer, ferritin, C-reactive protein) and clinical scores (SOFA) did not differ significantly between survivors and non-survivors. An optimal cut-off value to predict increased risk for 30-day all-cause mortality was 16.5 pg/mL for hs-cTnT (OR 8.5, 95% CI: 2.9, 25.0) and 415.5 pg/ml for NT-proBNP (OR 5.1, 95% CI: 1.8, 14.7).Conclusion: Myocardial injury in COVID-19 is common. Early detection of elevated hs-cTnT and NT-proBNP are predictive for 30-day mortality in patients with critical COVID-19. These markers outperform other routinely used biomarkers, as well as clinical indices of disease severity in ICU. The additive value of routine transthoracic echocardiography is disputable and should only be considered if it is likely to impact therapeutic management.

Effects of different anesthesia methods on maternal and neonatal outcomes in pregnant patients with pulmonary arterial hypertension: a meta-analysis.

To investigate the effects of different anesthesia methods on maternal and neonatal outcomes in pregnant patients with pulmonary arterial hypertension (PAH). We searched PubMed, Excerpta Medica Database (EMBASE), Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Wanfang and QVIP for investigating the effects of general anesthesia (GA) and local anesthesia (LA) in pregnant patients with PAH. Results were expressed as weighted mean difference (WMD) or risk ratio (RR) with 95% confidence intervals (CIs). Publication bias was assessed by the Begg's test. Totally, 18 articles containing 628 LA and 481 GA patients were involved in our study. The postoperative blood oxygen saturation (WMD = - 4.040, 95%CI: - 5.505 to - 2.576) and maternal mortality rate (RR = 0.507, 95%CI: 0.300-0.858) were lower in LA group than those in GA group. The postoperative systolic blood pressure (WMD = 15.647, 95%CI: 13.294-18.000) and postoperative diastolic blood pressure (WMD = 6.758, 95%CI: 5.715-7.802) were high in LA group compared with those in GA group. The mechanical ventilation time (WMD = - 4.112, 95%CI: - 4.655 to - 3.569), ICU admission time (WMD = - 4.176, 95%CI: - 4.523 to - 3.828), length of stay (WMD = -7.289, 95%CI: -7.799-6.779) were shorter in LA group than those in GA group. All P values were < 0.05. LA is superior to GA in regards to the postoperative blood oxygen saturation, the postoperative systolic blood pressure, postoperative diastolic blood pressure, the mechanical ventilation time, ICU admission time, length of stay and the maternal mortality rate. osf.io/juybq ( https://osf.io/search/ ).

The predictive value of cardiac biomarkers and echocardiography in critical COVID-19

Abstract Background Coronavirus disease (COVID-19) continues to challenge healthcare systems worldwide. Adequate triage and divergence to an appropriate level of care are essential. Myocardial injury is a common finding in COVID-19 patients, while cardiac complications seem to occur only in a minority of patients. Purpose To evaluate cardiac biomarkers and echocardiographic findings in critical COVID-19 at time of ICU admission, and to assess their association with ICU mortality in comparison to other biomarkers and risk factors. Methods Prospective, single-center, cohort study in patients with PCR-confirmed COVID-19 admitted to the ICU. Laboratory assessment included high sensitive troponin T (hsTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP). Standard transthoracic echocardiographic evaluation was performed upon ICU admission. The primary outcome was ICU mortality. Statistical analysis was performed using SPSS statistics (Version 27.0, IBM Corp, Armonk, NY) with χ2 and Mann–Whitney U tests. Predictive markers for mortality were assessed by ROC analysis and cut-off values by the Youden Index. Results We included 86 patients. Transthoracic echocardiography was not feasible in 11 patients (12.8%) due to poor visualization or prone ventilation. Baseline characteristics are presented in the table. Left ventricular ejection fraction (LVEF) was below 50% in 18.7% of patients and 20% had an E/e' septal ratio above 14. Right ventricular function, evaluated with TAPSE, was normal (&amp;gt;14mm) in 94% of patients. Cardiac biomarkers were elevated in almost half of all patients (hsTnT ≥14 μg/L in 46.5%, and NT-proBNP ≥450 pg/mL in 44,2%), and in up to 30% of patients with normal LVEF. The level of these cardiac biomarkers was significantly higher in non-survivors, while other routinely used biomarkers (D-dimers, ferritin, C-reactive protein), and commonly used clinical scores indicating the severity of illness (SOFA score) were not. A cut-off value of 16.5 μg/L for hsTnT corresponded with sensitivity and specificity for mortality of resp. 75% and 74.2%. For NT-proBNP, a cut-off value of 760 pg/mL corresponded with sensitivity and specificity for mortality of resp. 60% and 83.3%. LVEF was significantly lower and E/e' ratio was significantly higher in non-survivors. Conclusion Echocardiographic abnormalities, especially left and not right ventricular dysfunction, were found in up to 20% of patients, whereas up to half of all patients had elevated cardiac biomarkers at time of ICU admission. This study highlights the strong predictive value of cardiac biomarkers for ICU mortality and their possible role for triage in critical COVID-19. They outperform routinely used biomarkers of inflammation as well as clinical indices of disease severity in ICU. Transthoracic echocardiography should only be considered if it is likely to impact therapeutic management given the potential hazard for sonographers and the scarcity of personal protective equipment. Funding Acknowledgement Type of funding sources: None.

Mid-term outcomes of off-pump versus on-pump coronary artery bypass graft surgery; statistical challenges in comparison

BackgroundDespite several studies comparing off- and on-pump coronary artery bypass grafting (CABG), the effectiveness and outcomes of off-pump CABG still remain uncertain.MethodsIn this registry-based study, we assessed 8163 patients who underwent isolated CABG between 2014 and 2016. Propensity score matching (PSM), inverse probability of weighting (IPW) and covariate adjustment were performed to correct for and minimize selection bias.ResultsThe overall mean age of the patients was 62 years, and 25.7% were women. Patients who underwent off-pump CABG had shorter length of hospitalization (p < 0.001), intubation time (p = 0.003) and length of ICU admission (p < 0.001). Off-pump CABG was associated with higher risk of 30-days mortality (OR: 1.7; 95% CI 1.09–2.65; p = 0.019) in unadjusted analysis. After covariate adjustment and matching (PSM and IPW), this difference was not statistically significant. After an average of 36.1 months follow-up, risk of MACCE and all-cause mortality didn’t have significant differences in both surgical methods by adjusting with IPW (HR: 1.03; 95% CI 0.87–1.24; p = 0.714; HR: 0.91; 95% CI 0.73–1.14; p = 578, respectively).ConclusionOff-pump and on-pump techniques have similar 30-day mortality (adjusted, PSM and IPW). Off-pump surgery is probably more cost-effective in short term; however, mid-term survival and MACCE trends in both surgical methods are comparable.

Effectiveness and safety of non invasive pressure ventilation in severe COVID-19 disease: A retrospective analysis

Noninvasive ventilation (NIV) has a controversial role in treating acute hypoxemic respiratory failure in Severe COVID-19 disease. Noninvasive ventilation has been known to avoid intubation and prevent complications associated with mechanical ventilation, but the risk of aerosolization and consequent contraction of disease deterred clinicians from using it.: The medical records of 18 patients having severe COVID -19 disease with Acute respiratory distress syndrome (ARDS), who received NIV therapy in a tertiary care hospital were scrutinized from a period of 15 June 2020 to 28 June 2020. The parameters like respiratory rate (RR)and PaO2/FiO2(PF ratio) and SOFA score were collected from the day of admission to 5th day of ICU stay. Other parameters like outcomes of NIV therapy, complications and time taken from weaning from NIV were recorded. Forty-five health care workers, involved in the treatment were educated about use of PPE and NIV and were tested for COVID -19 by RT-PCR post-ICU rotation.: The statistical analysis was done by statistical package for social science version(SPSS) 22.0. The parameters were compared by using repeated measure analysis of variance.The mean age group of the patient in the study was 47.44 years. The respiratory rate and PaO2/FIO2 at the time of ICU admission were 29.28±3.74 per minute and 121.06±29.05 respectively. There was significant improvement in PF ratio throughout the observation (p=0.021) and the respiratory rate decreased after NIV therapy from the day of admission to the subsequent days (p=0.001). The major proportion (i.e. 88.8%) of patients with ARDS but SOFA score &amp;#60;5, had a favorable outcome with NIV therapy. 45 HCWs tested negative for SARS-CoV-2. Non-invasive ventilation can be safely used as an effective therapy for moderate to severe ARDS due to COVID-19 disease.

Case fatality rate and survival functions of severe COVID–19 patients in intensive care unit of Bangabandhu Sheikh Mujib Medical University in Bangladesh: an observational study

Background: Emergence of current pandemic caused by novel SARS–COV–2 has already caused over 963000 deaths. Case fatality rate (CFR) estimation helps understanding the disease severity and the lethality trend, high risk population and subsequently, optimization of quality healthcare facilities. Our observational study aimed to find out existing trends in treating the most vulnerable group with scarce medical resource allocation and to implement necessary support services to comply with the ensuing need for best possible outcomes in our ICU. Methodology: In this observational study, all COVID–19 diagnosed patients admitted in our ICU from July 4, 2020 to September 22, 2020, were enrolled. Data were obtained from the core ICU register of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Information accumulated on predesigned data sheets comprised of particulars of patients, co–morbidities, duration of ICU stay, mode of oxygenation, organ support and quick SOFA scores. Total deaths in ICU (in hospital or referred from outside of BSMMU) were recorded. Results: The results revealed that all patients were either very severe or critically sick with COVID–19 pneumonia at the time of ICU admission. Out of 174 patients, 46 (26.44%) were put on invasive ventilation and the rest received noninvasive ventilation in the form of NRM, high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP or BiPAP), CTEX CPAP and non–invasive ventilation (NIV) as appropriate. Male and female ratio was 74:26. Age of patients ranged between 19–95y. The median age of patients was 65 y (IQR: 57–70).Quick SOFA scores were more than 2 in 65.37% of patients. Regarding co–existing organ dysfunction 13.8% had 3 or more co–morbidities; while 74.1% had 2 and 9.8% had a single systemic illness along with COVID–19. Most common diseases encountered among 135 deceased were hypertension (64%), IHD (49%), diabetes mellitus (45%), bronchial asthma or COPD (32%), renal failure (either ARF or CRF) (20%). Overall CFR due to COVID–19 pneumonia associated with co–morbidities was 77.6%. Relatively higher CFR (82.6%) was evident harboring multi–organ dysfunction especially among COVID–19 patients aged 50y or more. Gender linked CFR were 81.4% and 66.7% in males and females respectively. Conclusion: High CFR demonstrates significant correlation with increasing age and co–morbidities and survival functions. Late presentation to the hospital and invasive mechanical ventilation also contributed to high CFR. Keywords: Case fatality rate; CFR; COVID–19; Intensive Care Unit; Survival function Abbreviations: CFR – Case fatality rate; NRM – Non-rebreathing mask; HFNC – high flow nasal cannula; CPAP – continuous positive airway pressure; BiPAP – Bi-level positive airway pressure; NIV – Non–invasive ventilation; IHD – Ischemic heart disease; ARF – Acute renal failure; CRF – Chronic renal failure Citation: Islam MS, Bhowmick DK, Parveen M, Kamal MM, Akhtaruzzaman AKM. Case fatality rate and survival functions of severe COVID–19 patients in intensive care unit of Bangabandhu Sheikh Mujib Medical University in Bangladesh: an observational study. Anaesth. pain intensive care 2021;25(4):443–449. DOI: Received: June 4, 2021, Reviewed: June 7, 2021, Accepted: June 12, 2021

Empirical Assessment of U.S. Coronavirus Disease 2019 Crisis Standards of Care Guidelines

Retrospective single-center study. ICUs at a large academic medical center in the United States. Adult, critically ill patients admitted to ICU, with 27 patients admitted for acute respiratory failure due to coronavirus disease 2019 and 37 patients admitted for diagnoses other than coronavirus disease 2019. Review of electronic health record. Many U.S. states released crisis standards of care guidelines with algorithms to allocate scarce healthcare resources during the coronavirus disease 2019 pandemic. We compared state guidelines that represent different approaches to incorporating disease severity and comorbidities: New York, Maryland, Pennsylvania, and Colorado. Following each algorithm, we calculated priority scores at the time of ICU admission for a cohort of patients with primary diagnoses of coronavirus disease 2019 and diseases other than coronavirus disease 2019 (n = 64). We assessed discrimination of 28-day mortality by area under the receiver operating characteristic curve. We simulated real-time decision-making by applying the triage algorithms to groups of two, five, or 10 patients. For prediction of 28-day mortality by priority scores, area under the receiver operating characteristic curve was 0.56, 0.49, 0.53, 0.66, and 0.69 for New York, Maryland, Pennsylvania, Colorado, and raw Sequential Organ Failure Assessment score algorithms, respectively. For groups of five patients, the percentage of decisions made without deferring to a lottery were 1%, 57%, 80%, 88%, and 95% for New York, Maryland, Pennsylvania, Colorado, and raw Sequential Organ Failure Assessment score algorithms, respectively. The percentage of decisions made without lottery was higher in the subcohort without coronavirus disease 2019, compared with the subcohort with coronavirus disease 2019. Inclusion of comorbidities does not consistently improve an algorithm's performance in predicting 28-day mortality. Crisis standards of care algorithms result in a substantial percentage of tied priority scores. Crisis standards of care algorithms operate differently in cohorts with and without coronavirus disease 2019. This proof-of-principle study demonstrates the feasibility and importance of empirical testing of crisis standards of care guidelines to understand whether they meet their goals.