Included Intensive Care Unit Mortality Research Articles

Relationship between the albumin-corrected anion gap and short-term prognosis among patients with cardiogenic shock: a retrospective analysis of the MIMIC-IV and eICU databases

ObjectivesWe aimed to investigate the association between the albumin-corrected anion gap (ACAG) and the prognosis of cardiogenic shock (CS).DesignA multicentre retrospective cohort study.SettingData were collected from the Medical Information Mart...

Effects of high-fat, low-carbohydrate enteral nutrition in critically ill patients: A systematic review with meta-analysis

Background & aimsHigh-fat, low-carbohydrate enteral nutrition has gained attention, with expectations of an improved respiratory condition, fewer complications, and lower mortality. The present study performed a systematic review and meta-analysis of randomized controlled trials to examine the effects of high-fat, low-carbohydrate enteral nutrition in critically ill adult patients. MethodsWe searched MEDLINE via Pubmed, Cochrane Central Register of Controlled Trials (CENTRAL), and ICHUSHI for randomized controlled trials comparing high-fat, low-carbohydrate enteral nutrition to standard enteral nutrition in critically ill adult patients who received enteral nutrition. The primary outcome was mortality. Secondary outcomes included intensive care unit (ICU) mortality, length of ICU stay, length of mechanical ventilation, and adverse events of diarrhea and gastric residual volume. We examined the risk of bias using the Cochrane risk-of-bias tool for randomized trials version 2. We assessed the overall certainty of evidence based on the Grading of Recommendations Assessment, Development, and Evaluation methodology. Synthesis results were calculated with risk ratios and 95% confidence intervals using a Mantel-Haenszel random-effects model. ResultsEight trials with 607 patients were included. The effects of high-fat, low-carbohydrate enteral nutrition on mortality did not significantly differ from those of standard enteral nutrition (62/280 [22.1%] vs. 39/207 [18.8%], risk ratios=1.14, 95% confidence intervals 0.80 to 1.62, P=0.47). No significant differences were observed in ICU mortality, ICU length of stay, diarrhea, or gastric residual volume between the two groups. However, high-fat, low-carbohydrate enteral nutrition was associated with a significantly shorter duration of mechanical ventilation (mean difference -1.72 days, 95% confidence intervals -2.93 to -0.50, P=0.005). ConclusionHigh-fat, low-carbohydrate enteral nutrition may not affect mortality, but may decrease the duration of mechanical ventilation in critically ill adult patients. Limitations include the small number of studies and potential for bias. Further research is needed to confirm these results and investigate effects on other outcomes and in a subgroup of patients requiring mechanical ventilation.

Impact of the timing of invasive mechanical ventilation in patients with sepsis: a multicenter cohort study

BackgroundThe potential adverse effects associated with invasive mechanical ventilation (MV) can lead to delayed decisions on starting MV. We aimed to explore the association between the timing of MV and the clinical outcomes in patients with sepsis ventilated in intensive care unit (ICU).MethodsWe analyzed data of adult patients with sepsis between September 2019 and December 2021. Data was collected through the Korean Sepsis Alliance from 20 hospitals in Korea. Patients who were admitted to ICU and received MV were included in the study. Patients were divided into ‘early MV’ and ‘delayed MV’ groups based on whether they were on MV on the first day of ICU admission or later. Propensity score matching was applied, and patients in the two groups were compared on a 1:1 ratio to overcome bias between the groups. Outcomes including ICU mortality, hospital mortality, length of hospital and ICU stay, and organ failure at ICU discharge were compared.ResultsOut of 2440 patients on MV during ICU stay, 2119 ‘early MV’ and 321 ‘delayed MV’ cases were analyzed. The propensity score matching identified 295 patients in each group with similar baseline characteristics. ICU mortality was lower in ‘early MV’ group than ‘delayed MV’ group (36.3% vs. 46.4%; odds ratio, 0.66; 95% confidence interval, 0.47–0.93; p = 0.015). ‘Early MV’ group had lower in-hospital mortality, shorter ICU stay, and required tracheostomy less frequently than ‘delayed MV’ group. Multivariable logistic regression model identified ‘early MV’ as associated with lower ICU mortality (odds ratio, 0.38; 95% confidence interval, 0.29–0.50; p < 0.001).ConclusionIn patients with sepsis ventilated in ICU, earlier start (first day of ICU admission) of MV may be associated with lower mortality.

Comparison Between Early and Late Tracheostomy in ICU Patients Including COVID-19 and Non-COVID-19 Patients: A Retrospective Cohort Study at a Tertiary Care Hospital.

Background Tracheostomy is a common intervention for intensive care unit (ICU) patients for various reasons. The superiority of early versus late tracheostomy is still unfounded for non-COVID-19 cases. The COVID-19 pandemic complicated the matter, as little literature was available on the ideal timing of tracheostomy for patients with COVID-19. Research question This study aimed to establish the superiority of early or late tracheostomy for COVID-19 and non-COVID-19 cases by comparing outcomes, including ICU mortality, ventilation days after tracheostomy, and ICU length of stay (LOS). Study design and methods A single-center retrospective cohort study was conducted on ventilated ICU patients both with and without COVID-19 at a university hospital between January 2020 and December 2021. During the study period, 1,393 ventilated patients were scanned, and 156 were found to be tracheostomized. Tracheostomy was considered to be early when performed within 10 days of intubation, after which it was considered to be late. Results Tracheostomy was performed early for 84/156 (53.8%) of tracheostomized patients and late for 72/156 (46.2%) of patients. The overall mortality was 42.9% (36/84) versus 69.4% (50/72) (P=0.001, OR=3.03, 95% CI=1.563-5.874), 31.4% versus 65.5% in the non-COVID-19 group and 60.6% versus 72.1% (P=0.005, OR=2.640, 95% CI=1.345-5.181) in the COVID-19 group for the early and late tracheostomy groups, respectively. Ventilation days were higher for the late tracheostomy group than for the early tracheostomy group in the non-COVID-19 group (17.10 versus 9.18 days, P<0.001). However, it was almost the same for the early and late tracheostomy groups in the COVID-19 group (14.15 versus 13.86 days,P=0.821). The ICU LOS was greater for the late tracheostomy group for both the COVID-19 and non-COVID-19 groups. Multivariate analysis revealed that ICU mortality is significantly associated with age, ventilation days, and ICU LOS. Interpretation The results of this study indicate that early tracheostomy was associated with lower mortality, fewer ventilation days, and shorter LOS in both the COVID-19 and non-COVID-19 groups.

Association between hyperglycemia at ICU admission and postoperative acute kidney injury in patients undergoing cardiac surgery: Analysis of the MIMIC-IV database

BackgroundThis study aimed to explore the correlation between hyperglycemia at intensive care unit (ICU) admission and the incidence of acute kidney injury (AKI) in patients after cardiac surgery. MethodsWe conducted a retrospective cohort study, in which clinical data were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Adults (≥18 years) in the database who were admitted to the cardiovascular intensive care unit after cardiac surgery were enrolled. The primary outcome was the incidence of AKI within 7 days following ICU admission. Secondary outcomes included ICU mortality, hospital mortality, ICU length of stay, and the 28-day and 90-day mortality. Multivariable Cox regression analysis was used to assess the association between ICU-admission hyperglycemia and AKI incidence within 7 days of ICU admission. Different adjustment strategies were used to adjust for potential confounders. Patients were divided into three groups according to their highest blood glucose levels recorded within 24 h of ICU admission: no hyperglycemia (<140 mg/dL), mild hyperglycemia (140–200 mg/dL), and severe hyperglycemia (≥200 mg/dL). ResultsOf the 6905 included patients, 2201 (31.9%) were female, and the median (IQR) age was 68.2 (60.1–75.9) years. In all, 1836 (26.6%) patients had severe hyperglycemia. The incidence of AKI within 7 days of ICU admission, ICU mortality, and hospital mortality was significantly higher in patients with severe admission hyperglycemia than those with mild hyperglycemia or no hyperglycemia (80.3% vs. 73.6% and 61.2%, respectively; 2.8% vs. 0.9% and 1.9%, respectively; and 3.4% vs. 1.2% and 2.5%, respectively; all P <0.001). Severe hyperglycemia was a risk factor for 7-day AKI (Model 1: hazard ratio [HR]=1.4809, 95% confidence interval [CI]: 1.3126 to 1.6707; Model 2: HR=1.1639, 95% CI: 1.0176 to 1.3313; Model 3: HR=1.2014, 95% CI: 1.0490 to 1.3760; all P <0.050). Patients with normal glucose levels (glucose levels <140 mg/dL) had a higher 28-day mortality rate than those with severe hyperglycemia (glucose levels ≥200 mg/dL) (4.0% vs. 3.8%, P <0.001). ConclusionsIn post-cardiac surgery patients, severe hyperglycemia within 24 h of ICU admission increases the risk of 7-day AKI, ICU mortality, and hospital mortality. Clinicians should be extra cautious regarding AKI among patients with hyperglycemia at ICU admission after cardiac surgery.

Practice and Predictors of Do-Not-Resuscitate Orders in a Tertiary-Care Intensive Care Unit in Saudi Arabia.

The objective of this study was to describe Do-Not-Resuscitate (DNR) practices in a tertiary-care intensive care unit (ICU) in Saudi Arabia, and determine the predictors and outcomes of patients who had DNR orders. This retrospective cohort study was based on a prospectively collected database for a medical-surgicalIntensive CareDepartment in a tertiary-care center in Riyadh, Saudi Arabia (1999-2017). We compared patients who had DNR orders during the ICU stay with those with "full code." The primary outcome was hospital mortality. The secondary outcomes included ICU mortality, tracheostomy, duration of mechanical ventilation, and length of stay in the ICU and hospital. Among 24790 patients admitted to the ICU over the 19-year study period, 3217 (13%) had DNR orders during the ICU stay. Compared to patients with "full code," patients with DNR orders were older (median 67 years [Q1, Q3: 55, 76] versus 57 years [Q1, Q3: 33, 71], p < 0.0001), were more likely to be females (43% versus 38%, p < 0.0001), had worse premorbid functional status (WHO performance status scores 4-5: 606[18.9%] versus 1894[8.8%], p < 0.0001), higher prevalence of comorbid conditions, and higher APACHE II score (median 28 [Q1, Q3: 23, 34] versus 19 [Q1, Q3: 13, 25], p < 0.0001) and were more likely to be mechanically ventilated (83% versus 55%, p < 0.0001). Patients had DNR orders were more likely to die in the ICU (67.8% versus 8.5%, p < 0.0001) and hospital (82.4% versus 18.1%, p < 0.0001). On multivariable logistic regression analysis, the following were associated with an increased likelihood of DNR status: increasing age (odds ratio (OR) 1.01, 95% confidence interval (CI) 1.01-1.02), higher APACHE II score (OR 1.09, 95% CI 1.08-1.10), and worse WHO performance status score. Patients admitted in recent years (2012-2017 versus 2002-2005) were less likely to have DNR orders (OR 0.35, 95% CI 0.32-0.39, p < 0.0001). Patients with DNR orders had higher ICU mortality, more tracheostomies, longer duration of mechanical ventilation and length of ICU stay compared to patients with with "full code" but they had shorter length of hospital stay. In a tertiary-care hospital in Saudi Arabia, 13% of critically ill patients had DNR orders during ICU stay. This study identified several predictors of DNR orders, including the severity of illness and poor premorbid functional status.

Prognostic value of high-sensitivity cardiac troponin in non-cardiac surgical patients in intensive care units

Type II myocardial injury following surgical procedures is associated with adverse outcomes. The prognostic value of high-sensitivity cardiac troponin (hs-cTn) due to type II myocardial injury in surgical patients admitted to intensive care unit (ICU) remains unclear. The aim of this study was to assess prognostic value of hs-cTn in type II acute myocardial injury in non-cardiac surgical patients requiring post-operative ICU admission. Retrospective analysis of patients admitted to two level III ICUs following surgery and had hs-cTn measured on the day of ICU admission. Patients who had type I acute myocardial infarction (AMI) during their admission were excluded from the study. The primary outcome was hospital mortality. Secondary outcomes included ICU mortality, ICU length of stay (LOS) and hospital LOS. A total of 420 patients were included. On univariable analysis, higher hs-cTn was associated with increased hospital mortality (14.6% vs 6.3%, p = 0.008), ICU LOS (41.1 h, vs 25 h, p = 0.004) and hospital LOS (253 h vs 193 h, p = 0.02). On multivariable analysis, hs-cTn was not independently associated with increased risk of hospital mortality. However, in patients who had elective surgery, hs-cTn was associated with increased risk (OR 1.048; 95% CI 1.004–1.094; p = 0.031) of hospital mortality with area under the receiver operating characteristic curve of 0.753 (95% CI 0.598–0.908). In elective surgical patients, hs-cTn was associated with increased risk of mortality. Larger multicentre studies are required to confirm this association that may assist in risk stratification of elective surgical patients requiring ICU admission.

The lactate to albumin ratio linked to all-cause mortality in critically ill patients with septic myocardial injury.

The lactate to albumin ratio (LAR) has emerged as a promising prognostic marker in critically ill patients. Despite its potential utility, the prognostic value of LAR in septic myocardial injury (SMI) remains uncertain. This study aims to investigate the prognostic significance of LAR in SMI through a retrospective cohort analysis of data from the Medical Information Mart for Intensive Care III (MIMIC-III) (v1.4) database. The study included intensive care unit (ICU)-admitted patients (age ≥18 years) diagnosed with SMI. The primary endpoint was in-hospital mortality. A total of 704 patients were included in the study, of which 59.10% were male. Hospital mortality and ICU mortality rates were recorded at 29.97% and 22.87%, respectively. After adjusting for confounding factors, multivariate Cox proportional risk analysis demonstrated that LAR was independently associated with an increased risk of both hospital mortality (HR, 1.39 [95% CI: 1.24-1.56] P < 0.001) and ICU mortality (HR, 1.46 [95% CI: 1.29-1.65] P < 0.001). Furthermore, the generalized additive model (GAM) and restricted cubic spline (RCS) model indicated a linear relationship between LAR and mortality rates in the ICU and hospital. The LAR may serve as a potential prognostic biomarker in critically ill patients with SMI. High LAR levels are associated with a higher risk of in-hospital mortality and can help identify individuals with high mortality rates. Overall, the findings emphasize the importance of using LAR as a tool for risk stratification and management of critically ill patients with SMI.

Rhesus factor is a stronger predictor for the risk of Sars-CoV-2 and mortality than ABO blood types

Abstract Objectives In this study, we aimed to evaluate the relationship between ABO blood groups and Rhesus factor (Rf) and severe acute respiratory syndrome coronavirus-2 (Sars-CoV-2), as well as the risk of infection susceptibility and death according to pre-existing comorbidities. Methods This retrospective study included patients medical record between March 2020 and March 2021. A total 470 patients were included in the study. The subjects were categorized according to diagnose of Sars-CoV-2. Also, we evaluated the subject according to severity of Sars-CoV-2 infection. The logistic and multivariate regression analysis were performed to predict possible effect of ABO and Rf types as well as comorbidities on indicators of Sars-CoV-2 severity including Intensive care unit (ICU) hospitalization, intubation, and mortality. Results The distribution of ABO blood type and Rf were not statistically different cases with and without Sars-CoV-2. Blood type B and A were the most groups in intubation and mortality among patients with Sars-CoV-2. However, ABO blood types had no significant effect on risk of Sars-CoV-2 and mortality while, Rf had a significantly effect on it. Additionally, Rf had a statistically significant effect on all severity indicators of Sars-CoV-2 but ABO had not. Conclusions While Rf was significantly associated with risk of Sars-CoV-2 and had a strong effect on ICU admission, intubation, and mortality, ABO groups were not associated with risk of disease. Intubation and mortality rates were higher in patients with blood group B (OR: 2.93 p:0.390 95 % CI [0.253–33.9], OR: 0.217 p:0.211 95 % CI [0.020–2.37]) and Rh factor + (OR: 1.63 p:0.027 95 % CI [0.046–0.828]).

Conservative versus conventional oxygen therapy in type I acute respiratory failure patients in respiratory intensive care unit, Zagazig University.

The present study aimed to assess the effect of a conservative (permissive hypoxemia) versus conventional (normoxia) protocol for oxygen supplementation on the outcome of type I respiratory failure patients admitted to respiratory intensive care unit (ICU). This randomized controlled clinical trial was carried out at the Respiratory ICU, Chest Department of Zagazig University Hospital, for 18 months, starting in July 2018. On admission, 56 enrolled patients with acute respiratory failure were randomized in a 1:1 ratio into the conventional group [oxygen therapy was supplied to maintain oxygen saturation (SpO2) between 94% and 97%] and the conservative group (oxygen therapy was administered to maintain SpO2 values between 88% and 92%). Different outcomes were assessed, including ICU mortality, the need for mechanical ventilation (MV) (invasive or non-invasive), and ICU length of stay. In the current study, the partial pressure of oxygen was significantly higher among the conventional group at all times after the baseline reading, and bicarbonate was significantly higher among the conventional group at the first two readings. There was no significant difference in serum lactate level in follow-up readings. The mean duration of MV and ICU length of stay was 6.17±2.05 and 9.25±2.22 days in the conventional group versus 6.46±2.0 and 9.53±2.16 days in the conservative group, respectively, without significant differences between both groups. About 21.4% of conventional group patients died, while 35.7% of conservative group patients died without a significant difference between both groups. We concluded that conservative oxygen therapy may be applied safely to patients with type I acute respiratory failure.

Severe Outcomes, Readmission, and Length of Stay Among COVID-19 Patients with Intellectual and Developmental Disabilities

ObjectivesThe aim of this study was to evaluate the association between intellectual and developmental disabilities (IDDs) and severe COVID-19 outcomes, 30-day readmission, and/or increased length of stay (LOS) using a large electronic administrative database. MethodsPatients hospitalized with COVID-19 were identified between March 2020 and June 2021 from more than 900 hospitals in the United States. IDDs included intellectual disability, cerebral palsy, Down syndrome, autism spectrum disorder (ASD), and other intellectual disabilities. Outcomes included intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), 30-day readmission, mortality, and LOS. ResultsAmong 643,765 patients with COVID-19, multivariate models showed that patients with any IDD were at a significantly greater risk of at least 1 severe outcome, 30-day readmission, or longer LOS than patients without any IDD. Compared with those without any IDD, patients with Down syndrome had the greatest odds of ICU admission (odds ratio [OR] and 95% confidence interval [CI]: 1.96 [1.73-2.21]), IMV (OR: 2.37 [2.07-2.70]), and mortality (OR: 2.33 [2.00-2.73]). Patients with ASD and those with Down syndrome both had over a 40% longer mean LOS. Patients with intellectual disabilities had a 23% (12-35%) increased odds of 30-day readmission. ConclusionsResults suggest that patients hospitalized with COVID-19 with IDD have a significantly increased risk of severe outcomes, 30-day readmission, and longer LOS.

Outcomes of septic cirrhosis patients admitted to the intensive care unit: A retrospective cohort study.

The aim of this study is to examine the outcome of septic patients with cirrhosis admitted to the intensive care unit (ICU) and predictors of mortality.Single center, retrospective cohort study.The study was conducted in Intensive care Department of King Abdulaziz Medical City, Riyadh, Saudi Arabia.Data was extracted from a prospectively collected ICU database managed by a full time data collector. All patients with an admission diagnosis of sepsis according to the sepsis-3 definition were included from 2002 to 2017. Patients were categorized into 2 groups based on the presence or absence of cirrhosis.The primary outcome of the study was in-hospital mortality. Secondary outcomes included ICU mortality, ICU and hospital lengths of stay and mechanical ventilation duration.A total of 7906 patients were admitted to the ICU with sepsis during the study period, of whom 497 (6.29%) patients had cirrhosis. 64.78% of cirrhotic patients died during their hospital stay compared to 31.54% of non-cirrhotic. On multivariate analysis, cirrhosis patients were at greater odds of dying within their hospital stay as compared to non-cirrhosis patients (Odds ratio {OR} 2.53; 95% confidence interval {CI} 2.04 – 3.15) independent of co-morbidities, organ dysfunction or hemodynamic status. Among cirrhosis patients, elevated international normalization ratio (INR) (OR 1.69; 95% CI 1.29-2.23), hemodialysis (OR 3.09; 95% CI 1.76-5.42) and mechanical ventilation (OR 2.61; 95% CI 1.60–4.28) were the independent predictors of mortality.Septic cirrhosis patients admitted to the intensive care unit have greater odds of dying during their hospital stay. Among septic cirrhosis patients, elevated INR and the need for hemodialysis and mechanical ventilation were associated with increased mortality.

Sepsis in end-stage renal disease patients: are they at an increased risk of mortality?

Objectives This study aims to examine the outcome of end-stage renal disease (ESRD) patients admitted with sepsis to the intensive care unit (ICU). Design Single centre, retrospective cohort study Setting The study was conducted in the Intensive Care Department of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Participants Data were extracted from a prospectively collected ICU database from 2002 to 2017. Patients were considered to have sepsis based on the sepsis-3 definition and were stratified into 2 groups based on the presence or absence of ESRD. Primary and secondary outcomes The primary outcome of the study was in-hospital mortality. Secondary outcomes included ICU mortality, ICU and hospital lengths of stay, and mechanical ventilation duration. Results A total of 8803 patients were admitted to the ICU with sepsis during the study period. 730 (8.3%) patients had ESRD. 49.04% of ESRD patients with sepsis died within their hospital stay vs. 31.78% of non-ESRD patients. ESRD septic patients had 1.44 greater odds of dying within their hospital stay as compared to septic non-ESRD patients (OR 1.44, 95% CI 1.03–1.53). Finally, the predictors of hospital mortality in septic ESRD patients were found to be mechanical ventilation (OR 3.36; 95% CI 2.27–5.00), a history of chronic liver disease (OR 2.26; 95% CI 1.26–4.07), and use of vasopressors (OR 1.74; 95% CI 1.19–2.54). Among patients with ESRD, hospital mortality was higher in subgroups of patients with chronic cardiac (OR 1.86 (1.36–2.53) vs. 1.19 (0.96–1.47)) and chronic respiratory illnesses (OR 2.20 (1.52–3.20) vs. 1.21 (0.99–1.48)). Conclusion ESRD patients admitted to the intensive care unit with sepsis are at greater odds of mortality compared to patients with non-ESRD. This risk is particularly increased if these patients have a concomitant history of chronic cardiac and respiratory illnesses. Key Messages Sepsis and bacterial infections are very common in ESRD patients and following cardiovascular disease; sepsis is the second leading cause of death in patients with ESRD. This study aims to examine the outcome of patients with end-stage renal disease (ESRD) patients admitted with sepsis to the intensive care unit (ICU). The results of this study have shown that end-stage renal disease is associated with greater odds of ICU and hospital mortality among septic patients admitted to an intensive care unit. ESRD patients were also more likely to be started on vasopressors and mechanical ventilation.

Safety and efficacy of routine diagnostic test reduction interventions in patients admitted to the intensive care unit: A systematic review and meta-analysis.

Reducing unnecessary routine diagnostic testing has been identified as a strategy to curb wasteful healthcare. However, the safety and efficacy of targeted diagnostic testing strategies are uncertain. The aim of this study was to systematically review interventions designed to reduce pathology and chest radiograph testing in patients admitted to the intensive care unit (ICU). A predetermined protocol and search strategy included OVID MEDLINE, OVID EMBASE and the Cochrane Central Register of Controlled Trials from inception until 20 November 2019. Eligible publications included interventional studies of patients admitted to an ICU. There were no language restrictions. The primary outcomes were in-hospital mortality and test reduction. Key secondary outcomes included ICU mortality, length of stay, costs and adverse events. This systematic review analysed 26 studies (with more than 44,00 patients) reporting an intervention to reduce one or more diagnostic tests. No studies were at low risk of bias. In-hospital mortality, reported in seven studies, was not significantly different in the post-implementation group (829 of 9815 patients, 8.4%) compared with the pre-intervention group (1007 of 9848 patients, 10.2%), (relative risk 0.89, 95% confidence intervals 0.79 to 1.01, P = 0.06, I2 39%). Of the 18 studies reporting a difference in testing rates, all reported a decrease associated with targeted testing (range 6%-72%), with 14 (82%) studies reporting >20% reduction in one or more tests. Studies of ICU targeted test interventions are generally of low quality. The majority report substantial decreases in testing without evidence of a significant difference in hospital mortality.

The incidence and outcomes of patients with acute kidney injury in a multidisciplinary intensive care unit in Durban, South Africa.

Background Acute kidney injury (AKI) in critically ill and resource-limited settings is under investigated. Objectives To describe the incidence, outcomes and healthcare burden of AKI in a multidisciplinary intensive care unit (ICU) in Durban, South Africa (SA). Methods All adult patients admitted to the ICU at King Edward VIII Hospital from January 2016 to June 2016, who did not have end-stage renal disease and survived for more than 6 hours after admission were evaluated for AKI using the kidney disease improving global outcomes (KDIGO) creatinine criteria. Potential risk factors for AKI and an association between AKI and outcomes including ICU mortality and length of stay were analysed. Results We screened 204 patients for inclusion into the study and 26 patients were excluded. About half of the patients (50.5%; n=90/178) who were included in the study were diagnosed with AKI at the time of admission and 16.3% (n= 29/178 developed AKI in the ICU. Among the patients who had AKI on admission, 50% (n=45/90) were classified as KDIGO stage1, 21.1% (n=19/90) as stage 2 and 28.8% (n=26/90) as stage 3. Less than one-third (24.7%; n=44/178) of the patients who developed AKI in the ICU were classified as KDIGO stage 1, 14% (n=25/178) were stage 2, and 28% (n=50/178) were stage 3. The mortality rate for patients with AKI on admission was 40.0% (n=36/90) compared with 39.8% (n=35/88) for those without AKI on admission (p=0.975). The mortality rate for all patients with AKI was 46.2% (n=55/119) compared with 27.1% (n=16/59) in patients who did not develop AKI (p=0.014). Conclusion AKI is common in critically ill patients presenting to a tertiary ICU in Durban, SA. AKI is associated with increased mortality and length of stay in the ICU. Strategies to prevent the development or worsening of AKI must be emphasised. These include prevention or at least early treatment of sepsis, adequate fluid resuscitation, aggressive haemodynamic optimisation and avoidance of nephrotoxins. This is especially important in settings where there is limited access to renal replacement therapy (RRT). Contributions of the study This is one of the first studies to describe the incidence and outcomes of AKI in a general critical care population in a resource-limited setting. The study highlights that AKI is very common in critically ill patients in a resource-limited setting, and is associated with increased mortality and resource utilisation. It also highlights the importance of sepsis as a risk factor for AKI.

Adding vitamin C to hydrocortisone lacks benefit in septic shock: a historical cohort study.

PurposeSepsis has high incidence and mortality rates, particularly in the intensive care unit (ICU). Corticosteroids may improve outcomes, and vitamin C may add benefit. We aimed to assess whether vitamin C and corticosteroids improved outcomes compared with corticosteroids alone.MethodsThis historical cohort study (11 December 2016 to 21 February 2018) was conducted in the ICU of a quaternary referral hospital. Patients with an ICU admission diagnosis of sepsis or septic shock who received vitamin C and hydrocortisone within 72 hr were compared with those who received only hydrocortisone. All patients received standard sepsis care including source control, antibiotics, and fluid resuscitation. Most patients received thiamine as standard ICU care. The primary outcome was hospital mortality. Secondary outcomes included ICU mortality, ventilator-free days, vasopressor-free days, dialysis use, and duration of ICU admission.ResultsOne hundred and forty-four patients were included in the study. The mean (standard deviation [SD]) age was 64 (15) yr; 39% were female; and the mean (SD) Acute Physiology And Chronic Health Evaluation IV score was 89 (30). Eighty-eight patients did not receive vitamin C and 52 received vitamin C. There was no observed difference in hospital mortality between the non-vitamin C (36%) and vitamin C (39%) groups (adjusted odds ratio for hospital death, 0.52; 95% confidence interval, 0.20 to 1.34; P = 0.18). There were no statistically significant differences in any secondary outcomes.ConclusionIn this small observational study of ICU patients with septic shock, the addition of vitamin C to hydrocortisone therapy did significantly affect hospital mortality or other measures of mortality or organ dysfunction.

An Innovative Individual-Level Socioeconomic Measure Predicts Critical Care Outcomes in Older Adults: A Population-Based Study.

Little is known about the impact of socioeconomic status (SES) as a key element of social determinants of health on intensive care unit (ICU) outcomes for adults. We assessed whether a validated individual SES index termed HOUSES (HOUsing-based SocioEconomic status index) derived from housing features was associated with short-term outcomes of critical illness including ICU mortality, ICU-free days, hospital-free days, and ICU readmission. We performed a population-based cohort study of adult patients living in Olmsted County, Minnesota, admitted to 7 intensive care units at Mayo Clinic from 2011 to 2014. We compared outcomes between the lowest SES group (HOUSES quartile 1 [Q1]) and the higher SES group (HOUSES Q2-4). We stratified the cohort based on age (<50 years old and ≥50 years old). Among 4134 eligible patients, 3378 (82%) patients had SES successfully measured by the HOUSES index. Baseline characteristics, severity of illness, and reason for ICU admission were similar among the different SES groups as measured by HOUSES except for larger number of intoxications and overdoses in younger patients from the lowest SES. In all adult patients, there were no overall differences in mortality, ICU-free days, hospital-free days, or ICU readmissions in patients with higher SES compared to lower SES. Among older patients (>50 years), those with higher SES (HOUSES Q2-4) compared to those with lower SES (HOUSES Q1) had lower mortality rates (hazard ratio = 0.72; 95% CI: 0.56-0.93; adjusted P = .01), increased ICU-free days (mean 1.08 days; 95% CI: 0.34-1.84; adjusted P = .004), and increased hospital-free days (mean 1.20 days; 95% CI: 0.45-1.96; adjusted P = .002). There were no differences in ICU readmission rates (OR = 0.74; 95% CI: 0.55-1.00; P = .051). Individual-level SES may be an important determinant or predictor of critical care outcomes in older adults. Housing-based socioeconomic status may be a useful tool for enhancing critical care research and practice.

Vitamin C, Hydrocortisone, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Analysis of Real-World Application.

A recent study suggested mortality benefits using vitamin C, hydrocortisone, and thiamine combination therapy (triple therapy) in addition to standard care in patients with severe sepsis and septic shock. In order to further evaluate the effects of triple therapy in real-world clinical practice, we conducted a retrospective observational cohort study at an academic tertiary care hospital. A total of 94 patients (47 in triple therapy group and 47 in standard care group) were included in the analysis. Baseline characteristics in both groups were well-matched. No significant difference in the primary outcome, hospital mortality, was seen between triple therapy and standard care groups (40.4% vs. 40.4%; p = 1.000). In addition, there were no significant differences in secondary outcomes, including intensive care unit (ICU) mortality, requirement for renal replacement therapy for acute kidney injury, ICU length of stay, hospital length of stay, and time to vasopressor independence. When compared to standard care, triple therapy did not improve hospital or ICU mortality in patients with septic shock. A randomized controlled trial evaluating the effects of triple therapy is necessary prior to implementing vitamin C, hydrocortisone, and thiamine combination therapy as a standard of care in patients with septic shock.

Critical care medicine in Taiwan from 1997 to 2013 under National Health Insurance.

Monitoring of trends in the use of the intensive care unit (ICU) and the outcomes of ICU patients is essential for the assessment of the effective use of ICU. This study aims to investigate the incidence and outcome of critical care admissions in Taiwan from 1997 to 2013. Patients >18 years who had ICU admission between January 1997 and December 2013 were identified from the National Health Insurance Research Database in Taiwan. The main outcomes including ICU mortality and ICU length of stay (LOS) were measured. A total of 3,451,157 patients with ICU admission were identified during the study period. The mean ICU LOS was 5.9±9.0 days and the overall ICU-mortality rate was 19.8%. The mean age of the patients was 65.4 years old, 58.0% were elderly (≥65 years old), 61.1% were male. Annual incidence of ICU admissions increased from 115,754 in 1997 (age-adjusted incidence: 1,130/100,000 population) to 244,820 in 2013 (incidence: 1,483/100,000 population) (P<0.0001). The admission rate was highest for patients 75-104 years old (8,074 per 100,000 population), and lowest for those 18-44 years old (298 per 100,000 population). Among ICU admission patients, the percentage of patients ≥75 years old significantly increased from 25.2% in 1997 to 38.3% in 2013 (P<0.0001). ICU LOS remained stable during the study period, but the annual mortality rate significantly decreased from 23.0% in 1997 to 16.3% in 2013. ICU admissions significantly increased from 1997 to 2013, especially for elderly patients, in contrast, the mortality rate of ICU patients significantly declined with time. In addition, the ICU LOS did not change during the study period.

Impact of Corticosteroids on Short- and Long-Term Mortality in Patients with Sepsis and Septic Shock: A Meta-Analysis with Trial Sequential Analysis

Background Findings on the benefits and harms of corticosteroids for sepsis and septic shock from published meta-analyses are conflicting. With new randomized evidence emerging, an updated analysis of best available evidence on the effects of corticosteroids in sepsis and septic shock is warranted. Methods We did a conventional and cumulative meta-analysis and trial sequential analysis. Ovid MEDLINE, Ovid Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and LILACS were searched until May 2, 2018. Two reviewers selected randomized controlled trials (RCTs) reporting benefits and harms of corticosteroids as compared to placebo, standard therapy or no steroids in patients with sepsis and septic shock and independently collected data of interest. Primary outcomes were short-term (14-day and 28-day) mortality and long-term (90-day, 180-day, 1-year) mortality. Secondary outcomes included intensive care unit (ICU)- and hospital mortality, shock reversal by day 7 and 28, length of ICU and hospital stay, sequential organ failure assessment (SOFA) score at day 7 and adverse events. Fixed-effect and random-effects models were used to provide pooled estimates on predefined outcomes. This study is registered with PROSPERO, number CRD 42018092849. Findings Thirty-four RCTs including 9,942 participants were included in this meta-analysis. Results showed that long course of low-dose corticosteroids could improve 28-day mortality (relative ratio (RR), 0.91; 95% confidence interval (CI), 0.86 to 0.97; I2=0%; high-quality evidence), ICU mortality (RR, 0.87; 95%CI, 0.79 to 0.95; I2=21%; moderate-quality evidence) and hospital mortality (RR, 0.89; 95%CI, 0.79 to 0.99; I2=40%; low-quality evidence). Meta-regression analyses confirmed the benefits of corticosteroids in14-day and 28-day mortality and indicated that the use of hydrocortisone at least 135mg per day for at least 87h was associated with significant benefits. However, this meta-analysis found no benefits for 90-day mortality from low-quality evidence (RR, 0.96; 95%CI, 0.85 to 1.09; I2=44%), 180-day mortality and 1-year mortality and about 38,340 participants were required for clarification of the effect of 90-day mortality. In terms of adverse events, long course of low-dose corticosteroids were associated with hyperglycaemia (RR, 1.20; 95%CI, 1. 09 to 1.32; I2=40%) and hypernatraemia (RR, 1.60; 95%CI, 1.26 to 2.02; I2=0%). Short course of high-dose corticosteroids showed no significant benefits in any of the predefined outcomes. Interpretation Long course (at least 87h) of low-dose (at least 135 mg per day) hydrocortisone could improve 28-day mortality of patients with sepsis and septic shock as well as ICU- and hospital mortality, with varied quality of evidence. However, it could not reduce long-term (90-day, 180-day and 1-year) mortality. Funding: None. Declaration of Interest: We declare no competing interests.