Ill Intensive Care Unit Patients Research Articles

Clinical pharmacist interventions in nutrition-and drug-related problems in critically ill patients with renal dysfunction: a non-randomized controlled study.

Critically ill intensive care unit (ICU) patients often face life-threatening drug-related problems (DRPs) and malnutrition. Clinical pharmacists (CPs) play a crucial role in mitigating these issues and improving outcomes. This study was designed to detect, prevent, reduce or resolve nutrition-related problems (NRPs) and DRPs in intensive care patients with renal dysfunction through clinical pharmacy services. This 9-month, prospective, non-randomized, controlled study was conducted in the ICU. During the intervention period (IP), CP recommendations addressing NRPs and DRPs were provided to the healthcare team. NRPs were evaluated using an expert-developed enteral nutrition consensus protocol, while DRPs were classified according to the Pharmaceutical Care Network Europe (PCNE) Classification for Drug-Related Problems Version 9.1. The study included 60 patients with a median age of 73 years (IQR: 60.5-80). A total of 504 DRPs (8.4 per patient) were identified across all patients. DRPs were decreased by 50% during the IP compared to the observation period (OP) (p < 0.001). The most common causes of DRPs were 'too low a drug dose' (22.2%), 'drug-drug interactions' (17%), and 'too high a drug dose' (16.4%). Of the recommendations made to the prescribing physician, 140 (97.9%) were accepted. In the IP, targeted calorie and protein supplementation was fully achieved in more patients (p < 0.05). The most common recommendations included 'changes in the rate of nutrition' (66.7%), 'vitamin supplementation' (16.7%), and 'changes in enteral nutrition products' (7.7%). This study highlights the high incidence of DRPs and malnutrition risk in ICU patients with renal dysfunction, emphasizing the vital role of clinical pharmacists. Their collaboration with healthcare professionals significantly reduced both DRPs and NRPs.

Comparing the Complications in Central Venous Catheterization by Ultrasound Guidance vs Anatomical Landmark Technique in Critical Ill ICU Patients

Objective: To compare the complication rates during central venous catheterization using ultrasound guidance versus the anatomical landmark technique in critical ill ICU patients. Methodology: A prospective comparative study was conducted in intensive care unit (ICU) of Farooq Teaching Hospital, Rawalpindi from December 2023 to June 2024. Total 127 critically ill ICU patients with acute surgical or medical conditions requiring central venous catheterization (CVC), such as hypotension, dehydration, or required blood resuscitation, where periphery approach was not feasible, underwent CVC insertion. Patients were randomly divided into two groups: one group underwent ultrasound-guided CVC insertion, while the other group used anatomical landmark technique. The rate of complications was measured between the groups. Results: Mean age of the patients was 46.5±11.2 years. The mean time from skin puncture to blood flashback was 104±172 sec in ultrasound group compared to 401±587 sec in landmark group. Among 127 patients, 61 underwent catheterization using ultrasound guidance, while 66 underwent catheterization using the anatomical landmark technique. The complication rates between the two groups were compared. The complications experienced by patients included multiple attempts (&gt;1 puncture), pneumothorax, improper cannulation, hematoma, arterial punctures, incisional bleeding, and ecchymosis. In ultrasound group, 11.5% of patients experienced complications, compared to 28.8% in anatomical landmark group (p = 0.016). Conclusion: Ultrasound-guided central venous catheterization was associated with fewer complications and a higher success rate (correct placement of the CVC), making it easier to perform. This procedure simplicity is linked to enhanced safety and patient comfort.

The impact of ketamine on outcomes in critically ill patients: a systematic review with meta-analysis and trial sequential analysis of randomized controlled trials.

This meta-analysis aims to evaluate the effects of ketamine in critically ill intensive care unit (ICU) patients. We searched for randomized controlled trials (RCTs) in PubMed, Scopus, and the Cochrane Library; the search was performed initially in January but was repeated in December of 2023. We focused on ICU patients of any age. We included studies that compared ketamine with other traditional agents used in the ICU. We synthesized evidence using RevMan v5.4 and presented the results as forest plots. We also used trial sequential analysis (TSA) software v. 0.9.5.10 Beta and presented results as TSA plots. For synthesizing results, we used a random-effects model and reported differences in outcomes of two groups in terms of mean difference (MD), standardized MD, and risk ratio with 95% confidence interval. We assessed the risk of bias using the Cochrane RoB tool for RCTs. Our outcomes were mortality, pain, opioid and midazolam requirements, delirium rates, and ICU length of stay. Twelve RCTs involving 805 ICU patients (ketamine group, n=398; control group, n=407) were included in the meta-analysis. The ketamine group was not superior to the control group in terms of mortality (in five studies with 318 patients), pain (two studies with 129 patients), mean and cumulative opioid consumption (six studies with 494 patients), midazolam consumption (six studies with 304 patients), and ICU length of stay (three studies with 270 patients). However, the model favored the ketamine group over the control group in delirium rate (four studies with 358 patients). This result is significant in terms of conventional boundaries (alpha=5%) but is not robust in sequential analysis. The applicability of the findings is limited by the small number of patients pooled for each outcome. Our meta-analysis did not demonstrate differences between ketamine and control groups regarding any outcome except delirium rate, where the model favored the ketamine group over the control group. However, this result is not robust as sensitivity analysis and trial sequential analysis suggest that more RCTs should be conducted in the future.

Decision tree model for early use of semi-elemental formula versus standard polymeric formula in critically ill Malaysian patients: A cost-effectiveness study.

Prevention of enteral feeding interruption (EFI) improves clinical outcomes of critically ill intensive care unit (ICU) patients. This leads to shorter ICU stays and thereby lowers healthcare costs. This study compared the cost of early use of semi-elemental formula (SEF) in ICU vs standard polymeric formula (SPF) under the Ministry of Health (MOH) system in Malaysia. A decision tree model was developed based on literature and expert inputs. An epidemiological projection model was then added to the decision tree to calculate the target population size. The budget impact of adapting the different enteral nutrition (EN) formulas was calculated by multiplying the population size with the costs of the formula and ICU length of stay (LOS). A one-way sensitivity analysis (OWSA) was conducted to examine the effect each input parameter has on the calculated output. Replacing SPF with SEF would lower ICU cost by MYR 1059 (USD 216) per patient. The additional cost of increased LOS due to EFI was MYR 5460 (USD 1114) per patient. If the MOH replaces SPF with SEF for ICU patients with high EFI risk (estimated 7981 patients in 2022), an annual net cost reduction of MYR 8.4 million (USD 1.7 million) could potentially be realized in the MOH system. The cost-reduction finding of replacing SPF with SEF remained unchanged despite the input uncertainties assessed via OWSA. Early use of SEF in ICU patients with high EFI risk could potentially lower the cost of ICU care for the MOH system in Malaysia.

Evaluation of Antibiotics and Clinical Outcomes along with Various Other Factors in Critically Ill Intensive Care Unit Patients

Intensive care units (ICUs) are special hospital wards that provide desired treatment and close monitoring of patients who are critically ill. Drug Utilization Reviews (DUR) is an authorized, structured, ongoing review of patient medication to ensure appropriate and rational medication use to yield positive outcomes. The aim of this study is to evaluate the antibiotics and clinical outcomes in intensive care unit (ICU) patients. This study was cross sectional retrospective (cohort), descriptive and clinical study including patients admitted in ICU of tertiary care hospitals. A total 400 patients (Male 53%) and (Female 47%) were admitted in ICU were analyzed in this study. Majority of patients were from age group between 41 to 60 years i.e., 50.2%. Patients evaluated in this study were suffering from many diseases and comorbidities majorly including respiratory, infectious, nephrology and urology diseases. Antibiotics, majorly penicillins were administered to 185 (46.2%) patients, flouroquinolones 162 (40.5%), cephalosporins 287 (71.8%), carbapenems 102 (25.5%), vancomycin 61 (15.2%) and metronidazole 217 (54.2%) patients. Total 52 (12.5%) patients underwent culture sensitivity test. Significant drug-drug interactions were seen in 64% patients. High mortality rate (72.8%) was seen in this study. It was observed that presence of NI and lack of CST enhanced mortality rate. CST is very important regarding choice of ICU patient’s antibiotic therapy. Current study identified factors affecting the clinical outcomes in terms of morbidity and mortality in the ICU patients. Antibiotics are prescribed in ICU abundantly. Due to presence of drug-drug interactions, nosocomial infections, comorbidities, not having culture sensitivity test (CST) and adverse reactions mortality rate was enhanced. Pharmacist led medication review will help in avoiding all these issues.

Accuracy of non-invasive cuffless blood pressure in the intensive care unit: Promises and challenges.

Continuous non-invasive cuffless blood pressure (BP) monitoring may reduce adverse outcomes in hospitalized patients if accuracy is approved. We aimed to investigate accuracy of two different BP prediction models in critically ill intensive care unit (ICU) patients, using a prototype cuffless BP device based on electrocardiogram and photoplethysmography signals. We compared a pulse arrival time (PAT)-based BP model (generalized PAT-based model) derived from a general population cohort to more complex and individualized models (complex individualized models) utilizing other features of the BP sensor signals. Patients admitted to an ICU with indication of invasive BP monitoring were included. The first half of each patient's data was used to train a subject-specific machine learning model (complex individualized models). The second half was used to estimate BP and test accuracy of both the generalized PAT-based model and the complex individualized models. A total of 7,327 measurements of 15 s epochs were included in pairwise comparisons across 25 patients. The generalized PAT-based model achieved a mean absolute error (SD of errors) of 7.6 (7.2) mmHg, 3.3 (3.1) mmHg and 4.6 (4.4) mmHg for systolic BP, diastolic BP and mean arterial pressure (MAP) respectively. Corresponding results for the complex individualized model were 6.5 (6.7) mmHg, 3.1 (3.0) mmHg and 4.0 (4.0) mmHg. Percentage of absolute errors within 10 mmHg for the generalized model were 77.6, 96.2, and 89.6% for systolic BP, diastolic BP and MAP, respectively. Corresponding results for the individualized model were 83.8, 96.2, and 94.2%. Accuracy was significantly improved when comparing the complex individualized models to the generalized PAT-based model in systolic BP and MAP, but not diastolic BP. A generalized PAT-based model, developed from a different population was not able to accurately track BP changes in critically ill ICU patients. Individually fitted models utilizing other cuffless BP sensor signals significantly improved accuracy, indicating that cuffless BP can be measured non-invasively, but the challenge toward generalizable models remains for future research to resolve.

Effect Of Exogenous Melatonin on the Incidence of Delirium and Its Association with Severity of Illness in Postoperative Surgical ICU Patients

Background: Delirium is common in critically ill intensive care unit (ICU) patients and has been documented in up to 87 percent of patients. Sleep deprivation and delirium have been associated. Alteration of melatonin production has been associated with delirium. Melatonin acts via melatonin receptors present in the suprachiasmatic nuclei (SCN) and promotes sleep by attenuating the wake-promoting signal from the SCN. Objective: To determine the relationship between exogenous melatonin and the incidence of delirium and its association of with severity of illness, measured in term of APACHE II, procalcitonin level at the time of admission and daily SOFA score. Patients and Methods: Design: Randomised placebo-control study. Setting: the study was conducted in critical care setting in a tertiary level ICU. Participants: Postoperative patients age between 20-60 years who are going to be ventilated more than 48 hours without any contraindication to enteral medications. Interventions: Study group received melatonin 5 mg through the enteral route. Main outcome measures: To determine the effect of exogenous melatonin on the incidence of delirium in postoperative patients who require mechanical ventilation for more than 24 hours. The secondary outcome measures are procalcitonin (PCT) value at admission and disease severity scores like APACHE II and SOFA. Results: No statistically significant difference was found in admission incidence of delirium or procalcitonin. Age was higher in those patients that developed delirium (p &lt; 0.05). Conclusions: Although the incidence of delirium is not affected by exogenous melatonin or higher APACHE scores, it had a significant correlation with higher procalcitonin, that in turn indicated an association with delirium and sepsis. It was found that there is increased risk of developing delirium with increasing age.

Effects of Parenteral Protein Concentrations in Critically Ill Patients in ICU

Abstract Background: Parenteral protein supplements can prevent deterioration of acute critical illness during admission at intensive care unit (ICU). This study aimed to evaluate the effect of parenteral proteins on ICU outcome and to compare the effect of two different protein concentrations on handgrip strength in critically ill patients. Materials and Methods: This prospective comparative study included 60 acute critically ill patients who had parenteral nutrition during their ICU stay. The patients were divided into two groups: a standard protein group who received protein concentration of 1 g/kg/day (group A) and a high-protein group who received protein concentration of 2 g/kg/day (group B). The nutrition was delivered through a central line and the separate bottles technique. Results: Nitrogen balance was more negative in group B compared to group A within the first 3 days. The handgrip strength on day 7 was significantly higher in group B than group A. The forearm thickness, quadriceps muscle thickness, and overall muscle thickness were significantly higher in group B on day 7. The durations of mechanical ventilation, ICU stay, and total hospital stay were not significantly different between both groups. The protein dose was not significantly associated with the overall 2-month mortality. Conclusion: High parenteral protein intake (2 g/kg/day) associated with better handgrip strength and significant improvement of muscle thickness at the end of the 1st week of follow-up. Studies with larger sample size and longer durations of follow-up are recommended.

Platelet Transfusion in Patients With Sepsis and Thrombocytopenia: A Propensity Score-Matched Analysis Using a Large ICU Database.

PurposeSepsis with thrombocytopenia is highly prevalent in critically ill intensive care unit (ICU) patients and is associated with adverse outcomes. Platelet transfusion is the primary treatment of choice. However, evidence for the beneficial effects of platelet transfusion in patients with sepsis and thrombocytopenia is scarce and low in quality. This study aimed to evaluate the association between platelet transfusion and mortality among ICU patients with sepsis and thrombocytopenia.Patients and MethodsUsing the Medical Information Mart for Intensive Care III database (v. 1.4), the outcomes of sepsis patients with platelet counts of ≤ 150,000/μL were compared between those who did and did not receive platelet transfusion. The primary outcomes were 28- and 90-day all-cause mortalities. The secondary outcomes were red blood cell (RBC) transfusion, ICU-free days, and hospital-free days. Propensity score matching was employed to assemble a cohort of patients with similar baseline characteristics.ResultsAmong 7,765 eligible patients, 677 received platelet transfusion and were matched with 677 patients who did not receive platelet transfusion according to propensity scores. Platelet transfusion, as compared with no platelet transfusion, was associated with an increased risk of 28-day all-cause mortality [36.9 vs. 30.4%, odds ratio (OR), 1.21; 95% confidence interval (CI), 1.01–1.46; p = 0.039], increased risk of 90-day all-cause mortality (50.8 vs. 44.6%, OR, 1.13; 95% CI, 1.00–1.31; p = 0.048), fewer mean (standard deviation) 28-day ICU-free days (15.88 ± 8.97 vs. 18.64 ± 8.33 days, p < 0.001), and fewer hospital-free days (10.29 ± 8.49 vs. 11.43 ± 8.85 days, p = 0.017). The rate of RBC transfusion was not significantly different between the platelet transfusion and non-transfusion groups (p = 0.149). The results were maintained across several subgroup and sensitivity analyses.ConclusionIn this study, platelet transfusion was associated with higher 28- and 90-day all-cause mortalities. These results suggest the potential hazards of platelet transfusion in ICU patients with sepsis and thrombocytopenia.

Non-invasive oxygenation support in acutely hypoxemic COVID-19 patients admitted to the ICU: a multicenter observational retrospective study

BackgroundNon-invasive oxygenation strategies have a prominent role in the treatment of acute hypoxemic respiratory failure during the coronavirus disease 2019 (COVID-19). While the efficacy of these therapies has been studied in hospitalized patients with COVID-19, the clinical outcomes associated with oxygen masks, high-flow oxygen therapy by nasal cannula and non-invasive mechanical ventilation in critically ill intensive care unit (ICU) patients remain unclear.MethodsIn this retrospective study, we used the best of nine covariate balancing algorithms on all baseline covariates in critically ill COVID-19 patients supported with > 10 L of supplemental oxygen at one of the 26 participating ICUs in Catalonia, Spain, between March 14 and April 15, 2020.ResultsOf the 1093 non-invasively oxygenated patients at ICU admission treated with one of the three stand-alone non-invasive oxygenation strategies, 897 (82%) required endotracheal intubation and 310 (28%) died during the ICU stay. High-flow oxygen therapy by nasal cannula (n = 439) and non-invasive mechanical ventilation (n = 101) were associated with a lower rate of endotracheal intubation (70% and 88%, respectively) than oxygen masks (n = 553 and 91% intubated), p < 0.001. Compared to oxygen masks, high-flow oxygen therapy by nasal cannula was associated with lower ICU mortality (hazard ratio 0.75 [95% CI 0.58–0.98), and the hazard ratio for ICU mortality was 1.21 [95% CI 0.80–1.83] for non-invasive mechanical ventilation.ConclusionIn critically ill COVID-19 ICU patients and, in the absence of conclusive data, high-flow oxygen therapy by nasal cannula may be the approach of choice as the primary non-invasive oxygenation support strategy.

Hyperchloremia in Critically Ill Patients in ICU: Review Article

Chloride (Cl) is required for the regulation of blood pressure, renal function, gastrointestinal homeostasis and decarboxylation/gas transport. "Dyschloremia" or levels of serum Cl beyond the normal range, is a frequent occurrence in intensive care units and seems to be mostly caused by iatrogenic procedures (i.e. intravenous infusion of fluids rich in Cl). Hypochloremia and hyperchloremia seem to be related to high risk of death in specified intensive care unit (ICU) groups, although the data is inconclusive. Hyperchloremia may be associated with higher hemodynamic unstable changes and need for vasopressors, in addition to hyperchloremic metabolic acidosis (e.g., following major surgeries). Nonetheless, the direct or indirect mediation of these effects is still uncertain. Additionally, new research suggests that individuals with advanced hyperchloremia have a higher risk of acute renal damage and require renal replacement treatment. Objective: The purpose of this study was to describe significant chloride-related outcomes in critical illness and to evaluate their relevance for everyday clinical practice and therapeutic alternatives.

Population pharmacokinetics of cefotaxime in intensive care patients

PurposeTo characterise the pharmacokinetics and associated variability of cefotaxime in adult intensive care unit (ICU) patients and to assess the impact of patient covariates.MethodsThis work was based on data from cefotaxime-treated patients included in the ACCIS (Antibiotic Concentrations in Critical Ill ICU Patients in Sweden) study. Clinical data from 51 patients at seven different ICUs in Sweden, given cefotaxime (1000–3000 mg given 2–6 times daily), were collected from the first day of treatment for up to three consecutive days. In total, 263 cefotaxime samples were included in the population pharmacokinetic analysis.ResultsA two-compartment model with linear elimination, proportional residual error and inter-individual variability (IIV) on clearance and central volume of distribution best described the data. The typical individual was 64 years, with body weight at ICU admission of 92 kg and estimated creatinine clearance of 94 mL/min. The resulting typical value of clearance was 11.1 L/h, central volume of distribution 5.1 L, peripheral volume of distribution 18.2 L and inter-compartmental clearance 14.5 L/h. The estimated creatinine clearance proved to be a significant covariate on clearance (p < 0.001), reducing IIV from 68 to 49%.ConclusionA population pharmacokinetic model was developed to describe cefotaxime pharmacokinetics and associated variability in adult ICU patients. The estimated creatinine clearance partly explained the IIV in cefotaxime clearance. However, the remaining unexplained IIV is high and suggests a need for dose individualisation using therapeutic drug monitoring where the developed model, after evaluation of predictive performance, may provide support.

Estimated ECG Subtraction method for removing ECG artifacts in esophageal recordings of diaphragm EMG

The accuracy of diaphragm electromyogram (EMGdi) derived parameters, as used in critically ill intensive care unit (ICU) patients, can be compromised due to electrocardiographic (ECG) interference in the EMGdi signal. Removal of ECG contamination from the esophageal recordings of the EMGdi is challenging due to spectral overlapping of EMG and ECG signals and because of variability in ECG shape and amplitude. Therefore, we designed an Estimated ECG Subtraction (EES) method, based on three steps: (1) identification of the timing of the ECG artifact without an ECG reference channel, (2) estimation of the normalized ECG, considering the EMGdi as noise, and (3) subtraction of the denormalized ECG estimate from the EMGdi recordings. We evaluated the EES method against the use of a single wavelet-based adaptive filter. Using EMGdi signals of ten ICU patients and simulated contaminated EMG, we demonstrated that the EES method yields uncontaminated EMGdi, and showed that it is more effective than a wavelet-based adaptive filter only. Implementation of this technique may offer means to improve diaphragm activity monitoring and control in clinical practice.

Safety and Efficacy of Apixaban For Therapeutic Anticoagulation in Critically Ill ICU Patients with Severe COVID-19 Respiratory Disease.

Introduction Despite the use of unfractionated heparin (UFH) or low molecular weight heparin (LMWH), rates of thromboembolic disease, and subsequent morbidity and mortality remain unacceptably high in patients with severe novel coronavirus disease 2019 (COVID-19) disease. Direct oral anticoagulants (DOACs), such as apixaban, have numerous purported benefits although the safety and efficacy of their use in intensive care unit (ICU) patients with severe COVID-19 has yet to be evaluated. Materials and Methods Single-center, retrospective cohort study of 21 ICU patients with severe COVID-19 respiratory disease treated with apixaban for atrial fibrillation (AFib), venous thromboembolism (VTE), catheter-induced thrombosis, and/or COVID-19-induced coagulopathy. The primary objective was to evaluate the incidence of bleeding events and secondary objectives included thromboembolic events, coagulation parameters, and mortality. Results Ninety percent of patients were non-White, 43% were obese, 90% had acute respiratory distress syndrome, and 76% required mechanical ventilation. Nearly half of (47.6%) also experienced renal dysfunction and required renal replacement therapy. Eighty-six percent of patients received prophylaxis or treatment with UFH or LMWH within the 24-hour period prior to apixaban initiation. Patients were initiated on apixaban for the treatment of suspected or confirmed VTE (67%) or AFib (33%). All coagulation parameters remained abnormal but stable throughout the 10-day monitoring period. No patients experienced any major bleeding events or thrombosis throughout the study period. There were four deaths during the follow-up period, all deemed unrelated to coagulopathy or bleeding. Conclusion Apixaban appeared safe and efficacious in ICU patients with severe COVID-19 disease. These data encourage future trials seeking to optimize anticoagulation strategies in patients with severe COVID-19.

Respiratory Support in Severely or Critically Ill ICU Patients With COVID-19 in Wuhan, China.

This case series aimed to describe the clinical characteristics of severely or critically ill patients with COVID-19 and compare the clinical characteristics of patients who received invasive respiratory support with those of patients who received noninvasive respiratory support. We included all confirmed severe or critical illness cases of COVID-19 admitted to the Intensive Care Unit (ICU) of Zhongnan Hospital of Wuhan University, a COVID-19-designated hospital, from January 8 to March 12, 2020. Cases were analyzed for epidemiological, demographic, clinical, APACHE II, SOFA, radiological features and laboratory data. Outcomes of all patients were followed up as of March 12, 2020. This newly emerging virus had caused 55 confirmed severe or critical illness cases in ICU of a COVID-19-designated hospital. Most of the infected patients were men; more than half had underlying diseases, including hypertension, coronary artery disease and diabetes. The median age was 63 years old. Common symptoms at onset of illness were fever, fatigue and dry cough. Five (9.1%) hospitalized patients were presumed to have been infected in the hospital, and 4 (7.3%) health care workers were infected in their work. Of the 55 confirmed severe or critical illness cases, 10 (18.2%) patients died during the follow-up period as of March 12 with the median follow-up period of 28 days (interquartile range 16–35). Nine patients received VV-ECMO for severe respiratory failure and 4 (44.4%) patients died. Moreover, 28 patients received invasive respiratory support and 14 (50.0%) patients died. In this single-center study, 55 severely or critically ill ICU patients were confirmed to have COVID-19 in Wuhan and the overall mortality was 29.1%. Totally 28 (50.9%) of severely or critically ill ICU patients received invasive respiratory support and 14 (50.0%) died during the follow-up period.

Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients.

ABSTRACTIntroductionEarly initiation of end-of-life (EOL) care in terminally ill patients can reduce the administration of unnecessary medications, minimize laboratory and radiological investigations, and avoid procedures that can provoke untoward complications without substantial benefits. This retrospective observational study was performed to compare early vs late initiation of EOL care in terminally ill ICU patients after the recognition of treatment futility.Materials and methodsThe medical records of all patients who were considered to be terminally ill any time after ICU admission between January 2014 and December 2018 were extracted from the ICU database. The patients who were recognized for treatment futility were eligible for inclusion. The patients who were already on EOL care prior to the ICU admission or whose diagnosis was unconfirmed were excluded from the study. The treatment futility was a subjective decision jointly undertaken by the primary physician and the intensivist based upon the disease stage and the available therapeutic options. The commencement of EOL care after recognition of treatment futility was divided into (a) early group (EG)—within 48 hours of decision of treatment futility and (b) late group (LG)—after 48 hours of recognition of treatment futility. Both the groups were compared for (a) ICU mortality, (b) length of ICU stay, (c) number of antibiotic-free days, (d) number of ventilator-free days, (e) number of medical and/or surgical interventions (insertion of central lines, drains, IABP, etc.), (f) number of blood and radiological investigations, and (g) satisfaction level of family members.ResultsOut of 107 terminally ill patients with diagnosis of treatment futility, 64 patients (59.8%) underwent early initiation of EOL against delayed initiation in 43 (40.2%) patients (1.3 ± 0.4 days vs 5.1 ± 1.6 days; p = 0.01). The patients in the late initiation group were younger in age (49 ± 3.6 years vs 66 ± 5.3 years; p = 0.03). The number of antibiotic-free days was higher in the early initiation group (12 ± 5.2 days vs 6 ± 7.5; p = 0.02). The number of medical and surgical interventions was lesser in the early initiation group (3.0 ± 0.7 episodes vs 12 ± 3.9 episodes; p = 0.007). The late initiation of EOL was caused by prognostic dilemma (30.2%), reluctance of the family members (44.1%), ambivalence of the primary physician (18.6%), and hesitancy of the intensivist (6.9%). The satisfaction level of the family members was similar in both the groups.ConclusionWe conclude that delayed initiation of EOL care in terminally ill ICU patients after recognition of treatment futility can increase the antibiotic usage and medical and/or surgical interventions with no effect on the satisfaction level of the family members.How to cite this articleChoudhuri AH, Sharma A, Uppal R. Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients. Indian J Crit Care Med 2020;24(6):404–408.

Using Machine Learning to Predict Early Onset Acute Organ Failure in Critically Ill Intensive Care Unit Patients With Sickle Cell Disease: Retrospective Study.

BackgroundSickle cell disease (SCD) is a genetic disorder of the red blood cells, resulting in multiple acute and chronic complications, including pain episodes, stroke, and kidney disease. Patients with SCD develop chronic organ dysfunction, which may progress to organ failure during disease exacerbations. Early detection of acute physiological deterioration leading to organ failure is not always attainable. Machine learning techniques that allow for prediction of organ failure may enable early identification and treatment and potentially reduce mortality.ObjectiveThe aim of this study was to test the hypothesis that machine learning physiomarkers can predict the development of organ dysfunction in a sample of adult patients with SCD admitted to intensive care units (ICUs).MethodsWe applied diverse machine learning methods, statistical methods, and data visualization techniques to develop classification models to distinguish SCD from controls.ResultsWe studied 63 sequential SCD patients admitted to ICUs with 163 patient encounters (mean age 30.7 years, SD 9.8 years). A subset of these patient encounters, 22.7% (37/163), met the sequential organ failure assessment criteria. The other 126 SCD patient encounters served as controls. A set of signal processing features (such as fast Fourier transform, energy, and continuous wavelet transform) derived from heart rate, blood pressure, and respiratory rate was identified to distinguish patients with SCD who developed acute physiological deterioration leading to organ failure from patients with SCD who did not meet the criteria. A multilayer perceptron model accurately predicted organ failure up to 6 hours before onset, with an average sensitivity and specificity of 96% and 98%, respectively.ConclusionsThis retrospective study demonstrated the viability of using machine learning to predict acute organ failure among hospitalized adults with SCD. The discovery of salient physiomarkers through machine learning techniques has the potential to further accelerate the development and implementation of innovative care delivery protocols and strategies for medically vulnerable patients.

Safety of Needle Electromyography in Critically Ill Patients

Introduction: To evaluate the safety of needle electromyography (EMG) in critically ill intensive care unit (ICU) patients who are on anticoagulants and have comorbidities that increase the risk of bleeding and infections.&#x0D; Methods: We conducted a retrospective chart review of critically ill patients who underwent needle EMG studies. The most common complications followed by needle EMG were reviewed and classified based upon common terminology criteria for adverse events (CTAC) criteria. Descriptive statistics were reported using the frequencies and percentages for categorical variables. The mean and interquartile range is used for continuous variables. All analyses were conducted using the Statistical Package for the Social Sciences (IBM SPSS Statistic Version 21, IMB Inc., Chicago, IL.&#x0D; Results: Twenty-nine patients were included. 17 (58.6%) were males with a mean age of 60.8 +/- 16.7 years. The mean PT, PTT, and INR were 15.2 sec, 36.5 seconds, and 1.13, respectively. Fourteen (48.2%) patients in this cohort were treated with low molecular weight heparin (LMWH), and an additional 8 (27.5%) patients were administered subcutaneous (SC) heparin for deep vein thrombosis prophylaxis. Therapeutic heparin was being used in 3 (10.3%) patients and sequential compression devices (SCDs) in 4 (13.7%) patients. A total of 228 muscles were tested. Among them, 38 (16.6%) were deep muscles. There were no major bleeding complications at the time of the procedure and for the next seven days in any of the patients, including those with multiple medical comorbidities. All our patients met the grade 1 scale in the severity of adverse events criteria proposed by CTCAE.&#x0D; Conclusion: Needle EMG is safe in critically ill ICU patients on anticoagulants and multiple comorbidities including those that increase the risk of bleeding and infection.

Impact of Thyroid Dysfunction in Correlation to Mortality Rate of the Critically ILL ICU Patients (Prospective Observational Study)

Abstract Background during critical illness, changes in circulating hormonal levels are a common phenomenon. These alterations are correlated with the severity and outcome of patients in intensive care unit (ICU). Thyroid hormone stays a key role in the maintenance of the body growth. Modulating metabolism and the immune system. Aim of the Work is to access the relation between thyroid dysfunction and mortality in critically ill patients and to access the strength of thyroid dysfunction as a predictor of mortality against APACHE II score and CRP, also to assess the additive effect of low FT3 and high APACHE II score as a predictor of mortality. Patients and Methods the study population (n = 40) included 21 males (52.2%) and 19 females (47.5). their age range from (21 years) to (91 years) were selected from critically ill patients admitted to El Demerdash hospital general ICU in the period from March 2017 to March 2018. Patients were divided into 2 groups according to 7th day thyroid profile: Group 1 Normal thyroid function group (24 patients). Group 2 thyroid dysfunction group (16 patients). Results the most significant abnormality between the 2 groups was TT3 and FT3. The patients in thyroid dysfunction group showed significantly higher APACHE II score and CRP but lower GCS. They also needed more mechanical ventilation with longer duration. There was no significant difference between the 2 study groups as regard cardiovascular complication. Conclusion our study also showed highly significant correlation between thyroid dysfunction and mortality. FT3 appeared to be better predictor of mortality among critically ill patients with AUC 83% and p value &amp;lt; 0.001 with sensitivity 99% and specificity 61%. The predictive value of FT3 for mortality increased by the addition of APACHE II score &amp;gt; 25.

Invasive Procedures and Length of Stay among Critically Ill Patients in ICU over Three Years: A Retrospective Study

Introduction: Intensive care unit (ICU) provides advanced specialized medical and nursing care for critically ill patients. Advanced monitoring techniques are needed to prevent physiologic deterioration, while the underlying disease treated and resolved. Frequents invasive procedure and treatment are used and affect the death rate and length of hospitalization. This study aimed to describe the variables associated with critically ill patients and describe the standard invasive procedures or treatments used among patients in ICU. Method: A retrospective comparative study which utilized the ICU electronic database. The data of 446 dead patients who have admitted to ICU between January 2014 and December 2016 as a case of sepsis, heart failure or COPD exacerbation were enrolled. Result: Almost of all patients had received intravenous fluid and vasoactive drugs. The mechanical ventilation support and insertion of the indwelling urethral catheter commonly used among patients with critical illnesses; 78.3%, 41.3% respectively. One-third of all sepsis and heart failure patients were received CVC during ICU stay; patients with sepsis illness had less hospital length of stay than patients with heart failure and COPD (p < 0.05). Also, patients with sepsis illness had less hospital LOS than patients with heart failure and COPD (p < 0.05). There were no significant differences between ICU length of stay based on patients critical illness. Conclusion: We found a reduction in the death number among sepsis, heart failure and COPD patients with move forwards in years, the variety of death rate depends on the type of invasive procedure and treatment performed for each illness, mechanical ventilation support and insertion of indwelling urethral catheter commonly used among patients with critical illnesses.