Independent Predictor Of Intensive Care Unit Mortality Research Articles

Positive fluid balance as a major predictor of clinical outcome of patients with sepsis/septic shock after ICU discharge

IntroductionSepsis and septic shock continue to be syndromes that carry a high mortality rate worldwide. Early aggressive fluid and vasopressor support have resulted in significant improvement in patient outcomes. The prognostic clinical significance of a positive fluid balance in septic intensive care unit (ICU) patients remains undetermined. MethodsWe collected data from 297 septic patients hospitalized in our general and medical ICUs at Soroka Medical Center between January 2005 and June 2011 and divided the 4 study groups into the following 4 fluid balances: group 1, patients with fluid balance at discharge from ICU (FBD) less than 10 L; group 2, patients with an FBD of 10 to 20 L; group 3, patients with an FBD of 20 to 30 L; and group 4, patients with FBD in excess of 30 L. ResultsThe ICU and in-hospital mortality rate was also significantly higher in groups 2 to 4 as compared with group 1 (P < .001 for both ICU and in-hospital mortality). The positive cumulative FBD was found to be an independent predictor of ICU mortality (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06; P < .001; Table 3) and in-hospital mortality (OR, 1.06; 95% CI, 1.03-1.08; P < .001; Table 5) and also to constitute a risk factor for new organ system dysfunction at hospital discharge (OR, 1.01; 95% CI, 1.01-1.013; P < .001; Table 6) in critically ill patients with severe sepsis/septic shock. ConclusionsAlthough it is a monocentric retrospective study, we suggest that positive cumulative fluid balance is one of the major factors that can predict the clinical outcome of critically ill patients during their ICU stay and after their discharge from the ICU.

Dermatomyositis and Polymyositis in the Intensive Care Unit: A Single-Center Retrospective Cohort Study of 102 Patients.

IntroductionPatients with idiopathic inflammatory myopathies (IIMs) are sometimes complicated with life-threatening conditions requiring intensive care unit (ICU) admission. In the past, owing to the low incidence of IIM, little was known about such patients. Our aim was to investigate the clinical features and outcomes of these patients and identify their risk factors for mortality.MethodsA retrospective study was performed of IIM patients admitted over an 8-year period to the medical ICU of a tertiary referral center in China. We collected data regarding demographic features, IIM-related clinical characteristics, reasons for admission, organ dysfunction, and outcomes. Independent predictors of ICU mortality were identified through multivariate logistic regression analysis.ResultsOf the 102 patients in our cohort, polymyositis (PM), dermatomyositis (DM), and clinically amyopathic dermatomyositis (CADM) accounted for 23.5%, 64.7%, and 11.7% respectively. The median duration from the onset of IIM to ICU admission was 4.3 months (interquartile range [IQR], 2.6–9.4 months). Reasons for ICU admission were infection alone (39.2%), acute exacerbation of IIM alone (27.5%), the coexistence of both (27.5%), or other reasons (5.8%). Pneumonia accounted for 97% of the infections; 63.2% of infections with documented pathogens were caused by opportunistic agents. Rapid progressive interstitial lung disease (RP-ILD) was responsible for 87.5% of acute exacerbation of IIM. The median Acute Physiology and Chronic Health Evaluation II (APACHE II) score on ICU day 1 was 17 (IQR 14–20). On ICU admission, acute respiratory failure (ARF) was the most common type (80.4%) of organ failure. The mortality rate in the ICU was 79.4%. Factors associated with increased ICU mortality included a diagnosis of DM (including CADM), a high APACHE II score, the presence of ARF, a decreased PaO2/FiO2 ratio, and a low lymphocyte count at the time of ICU admission.ConclusionsThe outcome of IIM patients admitted to the ICU was extremely poor. A diagnosis of DM/CADM, the presence and severity of ARF, and the lymphocyte counts at ICU admission were shown to be valuable for predicting outcome. Opportunistic infections and rapidly progressive interstitial lung disease warrant concern in treating these patients.

The association between lactate, mean arterial pressure, central venous oxygen saturation and peripheral temperature and mortality in severe sepsis: a retrospective cohort analysis.

BackgroundDuring resuscitation in severe sepsis and septic shock, several goals are set. However, usually not all goals are equally met. The aim of this study is to determine the relative importance of the different goals, such as mean arterial pressure (MAP), lactate, central venous oxygen saturation (ScvO2) and central to forefoot temperature (delta-T), and how they relate to intensive care unit (ICU) and hospital mortality.MethodsIn a retrospective cohort study in a 20-bed mixed medical and surgical ICU of a teaching hospital we studied consecutive critically ill patients who were admitted for confirmed infection and severe sepsis or septic shock between 2008 and 2014. All validated MAP, lactate levels, ScvO2 and delta-T for the first 24 hours of ICU treatment were extracted from a clinical database. Logistic regression analyses were performed on validated measurements in the first hour after admission and on mean values over 24 hours. Patients were categorized by MAP (24-hour mean below or above 65 mmHg) and lactate (24-hour mean below or above 2 mmol/l) for Cox regression analysis.ResultsFrom 837 patients, 821 were eligible for analysis. All had MAP and lactate measurements. The delta-T was available in 812 (99 %) and ScvO2 was available for 193 out of these patients (23.5 %). Admission lactate (p < 0.001) and admission MAP (p < 0.001) were independent predictors of ICU and hospital mortality. The 24-hour mean values for lactate, MAP and delta-T were all independent predictors of ICU mortality. Hospital mortality was independently predicted by the 24-hour mean lactate (odds ratio (OR) 1.34, 95 % confidence interval (CI) 1.30–1.40, p = 0.001) mean MAP (OR 0.96, 95 % CI 0.95–0.97, p = 0.001) and mean delta-T (OR 1.09, 95 % CI 1.06–1.12, p = 0.001). Patients with a 24-hour mean lactate below 2 mmol/l and a 24-hour mean MAP above 65 mmHg had the best survival, followed by patients with a low lactate and a low MAP.ConclusionsAdmission MAP and lactate independently predicted ICU and hospital mortality. The 24-hour mean lactate, mean MAP and mean delta-T independently predicted hospital mortality. A Cox regression analysis showed that 24-hour mean lactate above 2 mmol/l is the strongest predictor for ICU mortality.

Rifampin use in acute community-acquired meningitis in intensive care units: the French retrospective cohort ACAM-ICU study.

IntroductionBacterial meningitis among critically ill adult patients remains associated with both high mortality and frequent, persistent disability. Vancomycin was added to treatment with a third-generation cephalosporin as recommended by French national guidelines. Because animal model studies had suggested interest in the use of rifampin for treatment of bacterial meningitis, and after the introduction of early corticosteroid therapy (in 2002), there was a trend toward increasing rifampin use for intensive care unit (ICU) patients. The aim of this article is to report on this practice.MethodsFive ICUs participated in the study. Baseline characteristics and treatment data were retrospectively collected from charts of patients admitted with a diagnosis of acute bacterial meningitis during a 5-year period (2004–2008). The ICU mortality was the main outcome measure; Glasgow Outcome Scale and 3-month mortality were also assessed.ResultsOne hundred fifty-seven patients were included. Streptococcus pneumoniae and Neisseria meningitidis were the most prevalent causative microorganisms. The ICU mortality rate was 15 %. High doses of a cephalosporin were the most prevalent initial antimicrobial treatment. The delay between admission and administration of the first antibiotic dose was correlated with ICU mortality. Rifampin was used with a cephalosporin for 32 patients (ranging from 8 % of the cohort for 2004 to 30 % in 2008). Administration of rifampin within the first 24 h of hospitalization could be associated with a lower ICU survival. Statistical association between such an early rifampin treatment and ICU mortality reached significance only for patients with pneumococcal meningitis (p=0.031) in univariate analysis, but not in the logistic model.ConclusionsWe report on the role of rifampin use for patients with community-acquired meningitis, and the results of this study suggest that this practice may be associated with lower mortality in the ICU. Nevertheless, the only independent predictors of ICU mortality were organ failure and pneumococcal infection. Further studies are required to confirm these results and to explain how rifampin use would reduce mortality.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-1021-7) contains supplementary material, which is available to authorized users.

Early Standard Electroencephalogram Abnormalities Predict Mortality in Septic Intensive Care Unit Patients.

IntroductionSepsis is associated with increased mortality, delirium and long-term cognitive impairment in intensive care unit (ICU) patients. Electroencephalogram (EEG) abnormalities occurring at the acute stage of sepsis may correlate with severity of brain dysfunction. Predictive value of early standard EEG abnormalities for mortality in ICU septic patients remains to be assessed.MethodsIn this prospective, single center, observational study, standard EEG was performed, analyzed and classified according to both Synek and Young EEG scales, in consecutive patients acutely admitted in ICU for sepsis. Delirium, coma and the level of sedation were assessed at the time of EEG recording; and duration of sedation, occurrence of in-ICU delirium or death were assessed during follow-up. Adjusted analyses were carried out using multiple logistic regression.ResultsOne hundred ten patients were included, mean age 63.8 (±18.1) years, median SAPS-II score 38 (29–55). At the time of EEG recording, 46 patients (42%) were sedated and 22 (20%) suffered from delirium. Overall, 54 patients (49%) developed delirium, of which 32 (29%) in the days after EEG recording. 23 (21%) patients died in the ICU. Absence of EEG reactivity was observed in 27 patients (25%), periodic discharges (PDs) in 21 (19%) and electrographic seizures (ESZ) in 17 (15%). ICU mortality was independently associated with a delta-predominant background (OR: 3.36; 95% CI [1.08 to 10.4]), absence of EEG reactivity (OR: 4.44; 95% CI [1.37–14.3], PDs (OR: 3.24; 95% CI [1.03 to 10.2]), Synek grade ≥ 3 (OR: 5.35; 95% CI [1.66–17.2]) and Young grade > 1 (OR: 3.44; 95% CI [1.09–10.8]) after adjustment to Simplified Acute Physiology Score (SAPS-II) at admission and level of sedation. Delirium at the time of EEG was associated with ESZ in non-sedated patients (32% vs 10%, p = 0.037); with Synek grade ≥ 3 (36% vs 7%, p< 0.05) and Young grade > 1 (36% vs 17%, p< 0.001). Occurrence of delirium in the days after EEG was associated with a delta-predominant background (48% vs 15%, p = 0.001); absence of reactivity (39% vs 10%, p = 0.003), Synek grade ≥ 3 (42% vs 17%, p = 0.001) and Young grade >1 (58% vs 17%, p = 0.0001).ConclusionsIn this prospective cohort of 110 septic ICU patients, early standard EEG was significantly disturbed. Absence of EEG reactivity, a delta-predominant background, PDs, Synek grade ≥ 3 and Young grade > 1 at day 1 to 3 following admission were independent predictors of ICU mortality and were associated with occurence of delirium. ESZ and PDs, found in about 20% of our patients. Their prevalence could have been higher, with a still higher predictive value, if they had been diagnosed more thoroughly using continuous EEG.

Risk factors for noninvasive ventilation failure in cancer patients in the intensive care unit: A retrospective cohort study

PurposeThe purpose of the study is to identify risk factors for noninvasive ventilation (NIV) failure in cancer patients with acute respiratory failure (ARF). Materials and methodsA retrospective cohort study of adult patients admitted to intensive care unit (ICU), who received NIV for treatment of ARF, was conducted. We conducted a chart review to estimate the NIV failure rate and used logistic regression to identify risk factors. ResultsOf 2258 patients admitted to the ICU during the study period, 114 (5%) received NIV for ARF. Noninvasive ventilation was successful in 67 patients (59%) and failed for 47 (41%), of whom 36 were intubated and 11 were sedated for palliation. Factors associated with NIV failure were infection as the primary cause of ARF (odds ratio [OR], 4.90; 95% confidence interval [CI], 1.78-13.45; P = .002), male sex (OR, 2.58; 95% CI, 1.20-5.56; P = .015), and Simplified Acute Physiology Score 3 (OR, 1.04; 95% CI, 1.01-1.07; P = .006). Overall ICU mortality was 40%, and hospital mortality was 56%. Noninvasive ventilation failure was the only independent predictor of ICU mortality (OR, 16.6; 95% CI, 6.5-41.5; P < .001). ConclusionsNoninvasive ventilation can avert ARF for most ICU cancer patients with ARF. For patients with pulmonary infections and high severity scores, NIV should be used with caution. Identifying risk factors for NIV failure using a comprehensive diagnostic approach and monitoring of NIV are paramount to improve outcomes.

Adult-onset idiopathic isolated central hypothyroidism: A case report and literature review

This study was conducted to determine the association between vasopressor requirement and outcome in medical intensive care patients in an environment where treatment is not withdrawn.This was an observational study of patients in the medical intensive care unit (ICU) over a period of 18 months to determine the correlation between vasopressor requirement and mortality. Outcome was determined for all medical ICU patients, for patients receiving “low dose” (< 40 μg/min) vasopressors (noradrenaline and/or adrenaline) or “high dose” (≥ 40 μg/min) vasopressors. Receiver operator characteristic curves were constructed for ICU and hospital mortality and high-dose vasopressor use. High-dose vasopressor use as an independent predictor for ICU and hospital mortality was also determined by multiple logistic regression analysis.Patients receiving high-dose noradrenaline at any time during their ICU admission had an 84.3% mortality in ICU and 90% in hospital. The receiver operator characteristic curves for high-dose vasopressors had an area under the curve of 0.799 for ICU mortality and 0.779 for hospital mortality. High-dose vasopressor was an independent predictor of ICU mortality, with an odds ratio of 5.1 (confidence interval, 2.02-12.9; P = .001), and of hospital mortality, with an odds ratio of 3.82 (confidence interval 1.28-11.37; P = .016).The requirement for high-dose vasopressor therapy at any time during ICU admission was associated with a very high mortality rate in the ICU and the hospital.

STREM-1 predicts intensive care unit and 28-day mortality in cancer patients with severe sepsis and septic shock

IntroductionThe innate immune response molecules and their use as a predictor of mortality in cancer patients with severe sepsis and septic shock are poorly investigated. ObjectiveTo analyze the value of interleukin (IL)-1ß, IL-6, IL-8, IL-10, IL-12, tumor necrosis factor α (TNF-α), soluble triggering receptor expressed on myeloid cells 1 (sTREM-1), and high-mobility group box 1 (HMGB-1) as predictors of mortality in cancer patients with severe sepsis and septic shock compared with septic patients without malignancies. DesignProspective, observational cohort study. SettingTertiary level adult intensive care unit (ICU). SubjectsSeventy-five patients with severe sepsis or septic shock, 40 with cancer and 35 without. Interventions and MeasurementsLaboratory data were collected at ICU admission, 24and 48 hours after. Plasma concentrations of HMGB-1 and sTREM-1 were measured by enzyme-linked immunosorbent assay, whereas cytokines were measured by cytometric bead array. ResultsIntensive care unit mortality in cancer and noncancer patients was 40% and 28.6% (P = .29), and 28-day mortality was 45% and 34.3% (P = .34). Proinflammatory cytokines IL-1ß, IL-6, IL-8, IL-12, and TNF-α showed significantly higher values in the cancer group. Interleukin-10 at 48 hours (P = .01), sTREM-1 in all measurements (P < .01) and HMGB-1 at 24 hours (P < .01) showed significantly lower values in the cancer group. In addition, for the cancer group, sTREM-1 at 24 hours (P = .02) and 48 hours (P = .01) showed higher levels in nonsurvivors patients. The area under the receiver operating characteristic curve for predicting ICU mortality for sTREM-1 was 0.73 (95% confidence interval, 0.57-0.89; P = .01). Multivariate logistic analysis showed that the days spent in mechanical ventilation and levels of sTREM-1 and IL-1ß at 48 hours were independent predictors of ICU mortality; corticosteroids requirement and levels of sTREM-1 and TNF-α at 24 hours were independent predictors of 28-day mortality. ConclusionsPatients with cancer have different immune profile in sepsis when compared with patients without cancer, as demonstrated for levels of cytokines, sTREM-1 and HMGB-1. sTREM-1 and days spent in mechanical ventilation proved to be good predictors of ICU and 28-day mortality in cancer patients.

Cardiac troponin I as a prognostic factor in critically ill pneumonia patients in the absence of acute coronary syndrome

PurposeElevated cardiac troponin (cTn) has been associated with worse outcomes in critically ill patients, but few studies have focused on whether these markers are related to outcomes in patients with severe pneumonia. We investigated the levels of cTnI in critically ill patients hospitalized for severe pneumonia and whether elevated levels of cTnI correlated with the clinical outcome of this patient group. Materials and methodsWe conducted a retrospective study of patients admitted to the medical intensive care unit (ICU) with severe pneumonia with levels of cTnI obtained within 24 hours of admittance. Patients with evidence of acute coronary syndrome were excluded. A cTnI level greater than 0.034 ng/mL was considered positive. P value < .05 was considered significant. ResultsA total of 152 patients (community-acquired pneumonia [39.5%], health care–associated pneumonia [40.8%], and hospital-acquired pneumonia [19.7%]) were included in the study. Eighty-eight (58%) patients had detectable cTnI levels (median, 0.049 ng/mL). Patients with increased cTnI levels showed higher in-ICU mortality (38.6% vs 21.9%, P = .028). The association between elevated cTnI levels and mortality remained significant after adjustment using a multivariate model (adjusted hazard ratio = 1.398; 95% confidence interval, 1.005-1.945; P = .047). ConclusionsIncreased levels of cTnI are an independent predictor of ICU mortality in patients hospitalized with severe pneumonia without evidence of acute coronary syndrome.

Hematologic malignancies in the medical intensive care unit – Outcomes and prognostic factors

ObjectivesTo analyze clinical characteristics, treatment, outcomes of critically ill patients with hematologic malignancies (HM) admitted to the medical intensive care unit (ICU) and to identify predictors of adverse outcome.MethodsWe analyzed prospectively 170 patients. Data included: demographic characteristics, hematologic diagnosis, reasons for ICU admission, transplant status, the presence of neutropenia, acute physiology and chronic health evaluation-II and sequential organ failure assessment scores, and level of organ support. Predictors of ICU mortality were evaluated using univariate and multivariate analysis.ResultsIn total, 73% of patients had high-grade malignancy, 47.6% received intensive chemotherapy before admission, and 30% underwent hematologic stem cell transplantation procedure. In total, 116 (68.2%) of patients were mechanically ventilated; 88 (51.8%) required invasive mechanical ventilation (MV). Non-invasive ventilation started in 28 (16.5%) patients and was successful in 11 (6.5%). The ICU mortality rate was 53.5%, and the mortality of MV patients was 75.9%. Need for vasopressors at admission and MV were identified as independent predictors of fatal outcome.ConclusionThe ICU mortality of critically ill patients with HM is high, particularly in the group of MV. Need for vasopressors at admission and MV were independent predictors of ICU mortality. Majority of patients required invasive MV due to severe respiratory failure and non-invasive MV was sufficient only in small number of cases with favorable outcome.

P147: Relationship between serum cystatin C level and prognosis in unselected ICU elderly patients

Objective: To study the relationship between the serum Cystatin C (Cys C) level and the prognosis of unselected ICU elderly patients admitted to intensive care unit (ICU). Methods: A total of 531 consecutive patients were screened for eligibility and followed up during their ICU stay. We collected each patient's baseline characteristics, including the Acute Physiology and Chronic Health Evaluation II (APACHEII) score and N-terminal pro-brain natriuretic peptide (NTproBNP), C-reactive protein (CRP) and Cys C levels. The primary outcome was ICU mortality in elderly patients. Multivariate logistic regression analysis was used to determine independent predictors of ICU mortality in elderly patients. We also evaluated the ability of Cys C and NT-proBNP together with APACHE-Ⅱ score to predict ICU mortality in elderly patients by calculation of net reclassification improvement (NRI) and integrated discrimination improvement (IDI) indices. Results: Multiple regression analysis revealed that Cys C level, APACHE-II score, NT-proBNP level and CRP level could independently predict primary outcome in unselected ICU Elderly Patients. APACHE-II had the greatest power to predict ICU mortality, as suggested by the largest area under the curve (AUC) of (0.784±0.020). The AUC for CRP level was less than that for NT-proBNP level (0.684±0.027) but greater than that for Cys C level (0.614±0.026) . The addition of Cys C level and NT-proBNP level to APACHE II score gave an NRI of 21.99% (p＜0.01) and an IDI of 8.12% (p＜0.01). The addition of Cys C to the APACHE-II score can obviously increase Cox & Snell R2 and Nagelkerke R2. IDI and NRI were statistically significant in higheGFR patients. Conclusion: In unselected ICU elderly patients, Cys C was an independent predictor of ICU mortality. The addition of Cys C level and NT-proBNP level to the APACHE-Ⅱ score could significantly improve the ability to predict ICU mortality in unselected ICU elderly patients. Cys C appeared to be more useful for predicting ICU outcomes in elderly patients with high eGFR.

Bicarbonate can improve the prognostic value of the MELD score for critically ill patients with cirrhosis

The prognosis of critically ill patients with cirrhosis is poor. Our aim was to identify an objective variable that can improve the prognostic value of the Model of End-Stage Liver Disease (MELD) score in patients who have cirrhosis and are admitted to the intensive care unit (ICU). This retrospective cohort study included 177 patients who had liver cirrhosis and were admitted to the ICU. Data pertaining to arterial blood gas-related parameters and other variables were obtained on the day of ICU admission. The overall ICU mortality rate was 36.2%. The bicarbonate (HCO3) level was found to be an independent predictor of ICU mortality (odds ratio, 2.3; 95% confidence interval [CI], 1.0–4.8; p = 0.038). A new equation was constructed (MELD-Bicarbonate) by replacing total bilirubin by HCO3 in the original MELD score. The area under the receiver operating characteristic curve for predicting ICU mortality was 0.76 (95% CI, 0.69–0.84) for the MELD-Bicarbonate equation, 0.73 (95% CI, 0.65–0.81) for the MELD score, and 0.71 (95% CI, 0.63–0.80) for the Acute Physiology and Chronic Health Evaluation II score. Bicarbonate level assessment, as an objective and reproducible laboratory test, has significant predictive value in critically ill patients with cirrhosis. In contrast, the predictive value of total bilirubin is not as prominent in this setting. The MELD-Bicarbonate equation, which included three variables (international normalized ratio, creatinine level, and HCO3 level), showed better prognostic value than the original MELD score in critically ill patients with cirrhosis.

Does high-dose vasopressor therapy in medical intensive care patients indicate what we already suspect?

PurposeThis study was conducted to determine the association between vasopressor requirement and outcome in medical intensive care patients in an environment where treatment is not withdrawn. Materials and MethodsThis was an observational study of patients in the medical intensive care unit (ICU) over a period of 18 months to determine the correlation between vasopressor requirement and mortality. Outcome was determined for all medical ICU patients, for patients receiving “low dose” (<40 μg/min) vasopressors (noradrenaline and/or adrenaline) or “high dose” (≥40 μg/min) vasopressors. Receiver operator characteristic curves were constructed for ICU and hospital mortality and high-dose vasopressor use. High-dose vasopressor use as an independent predictor for ICU and hospital mortality was also determined by multiple logistic regression analysis. ResultsPatients receiving high-dose noradrenaline at any time during their ICU admission had an 84.3% mortality in ICU and 90% in hospital. The receiver operator characteristic curves for high-dose vasopressors had an area under the curve of 0.799 for ICU mortality and 0.779 for hospital mortality. High-dose vasopressor was an independent predictor of ICU mortality, with an odds ratio of 5.1 (confidence interval, 2.02-12.9; P = .001), and of hospital mortality, with an odds ratio of 3.82 (confidence interval 1.28-11.37; P = .016). ConclusionsThe requirement for high-dose vasopressor therapy at any time during ICU admission was associated with a very high mortality rate in the ICU and the hospital.

Epidemiology, Clinical Features, and Prognosis of Elderly Adults with Severe Forms of Influenza A (H1N1)

To examine epidemiological and clinical data of individuals aged 65 and older with influenza virus A (H1N1) admitted to the intensive care unit (ICU) and to identify independent predictors of ICU mortality. Prospective, observational, multicenter study to determine prognostic factors in individuals infected with influenza A (H1N1) admitted to the ICU. One hundred forty-eight Spanish ICUs. Individuals with influenza A (H1N1) confirmed using real-time polymerase chain reaction from April 2009 to July 2011. Individuals aged 65 and older were compared with younger individuals. A multivariate analysis was conducted to determine independent predictors of mortality in this population. One thousand one hundred twenty individuals (129 (11.5%) aged 65) were included. Prevalence of chronic diseases was more common in older individuals. Viral pneumonitis was more frequent in individuals younger than 65 (70.5% vs 54.3%, P < .001). In older individuals, Acute Physiology and Chronic Health Evaluation II score (odds ratio (OR) = 1.11, 95% confidence interval (CI) = 1.11–1.20, P = .002), immunosuppression (OR = 3.66, 95% CI, 1.33–10.03, P = .01) and oseltamivir therapy initiated after 48 hours (OR = 3.32, 95% CI = 1.02–10.8, P = .04) were identified as independent variables associated with mortality. Corticosteroid use was associated with a trend toward greater mortality (OR = 2.39, 95% CI = 0.98–5.91, P = .06). Individuals aged 65 and older with influenza A (H1N1) admitted to the ICU have a higher incidence of underlying diseases than younger individuals and differences in clinical presentation. Early oseltamivir therapy is associated with better outcomes in elderly adults.

Combined enteral feeding and total parenteral nutritional support improves outcome in surgical intensive care unit patients

BackgroundFor intensive care unit (ICU) patients with gastrointestinal dysfunction and in need of total parenteral nutrition (TPN) support, the benefit of additional enteral feeding is not clear. This study aimed to investigate whether combined TPN with enteral feeding is associated with better outcomes in surgical intensive care unit (SICU) patients. MethodsClinical data of 88 patients in SICU were retrospectively collected. Variables used for analysis included route and percentage of nutritional support, total caloric intake, age, gender, body weight, body mass index, admission diagnosis, surgical procedure, Acute Physiology and Chronic Health Evaluation (APACHE) II score, comorbidities, length of hospital stay, postoperative complications, blood glucose values and hospital mortality. ResultsWound dehiscence and central catheter infection were observed more frequently in the group of patients receiving TPN calories less than 90% of total calorie intake (p = 0.004 and 0.043, respectively). APACHE II scores were higher in nonsurvivors than in survivors (p = 0.001). More nonsurvivors received TPN calories exceeding 90% of total calorie intake and were in need of dialysis during ICU admission (p = 0.005 and 0.013, respectively). Multivariate analysis revealed that the percentage of TPN calories over total calories and APACHE II scores were independent predictors of ICU mortality in patients receiving supplementary TPN after surgery. ConclusionIn SICU patients receiving TPN, patients who could be fed enterally more than 10% of total calories had better clinical outcomes than patients receiving less than 10% of total calorie intake from enteral feeding. Enteral feeding should be given whenever possible in severely ill patients.

Acute Respiratory Distress Syndrome in Nontrauma Surgical Patients: A 6-Year Study

Acute respiratory distress syndrome (ARDS) has been shown to increase morbidity but not mortality in trauma patients; however, little is known about the effects of ARDS in nontrauma surgical patients. The purpose of this study is to evaluate the risk factors for and outcomes of ARDS in nontrauma surgical patients. A prospective observational study was performed in the surgical intensive care unit (ICU) of an academic tertiary care center. From 2000 to 2005, all nontrauma surgical admissions to the surgical ICU were evaluated daily for ARDS based on predefined diagnostic criteria. Logistic regression analysis identified independent predictors for ARDS and ICU mortality. Of 2,046 patient identified, 125 (6.1%) met criteria for ARDS. The incidence of ARDS declined annually from 12.2% to 2.1% during the study period (p < 0.001). ARDS patients were significantly older (55.4 years vs. 51.8 years, p = 0.014) and more likely to be obese (32% vs. 22%, p = 0.007) than the non-ARDS population. Independent predictors of ARDS included use of pressors (relative risk, RR = 3.30), sepsis (RR = 1.72), and body mass index >or=30 kg/m (RR = 1.57). Independent predictors of ICU mortality included ARDS (RR = 6.88), pressors (RR = 2.85), positive fluid balance (RR = 2.27), Acute Physiology and Chronic Health Evaluation II (RR = 1.04), and age (RR = 1.02). Unlike trauma patients, ARDS was an independent predictor of ICU mortality in nontrauma surgical patients, independent of age and disease severity. Nontrauma surgical patients who developed ARDS were older, sicker, and had a longer ICU stay. Independent predictors of ARDS included use of pressors, sepsis, and obesity.

Relative adrenal insufficiency: an identifiable entity in nonseptic critically ill patients?

To determine whether relative adrenal insufficiency (RAI) can be identified in nonseptic hypotensive patients in the intensive care unit (ICU). Retrospective study in a medical-surgical ICU of a university hospital. One hundred and seventy-two nonseptic ICU patients (51% after trauma or surgery), who underwent a short 250 microg ACTH test because of > 6 h hypotension or vasopressor/inotropic therapy. On the test day, the Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) score were calculated to estimate disease severity. The ICU mortality until day 28 was recorded. Best discriminative levels of baseline cortisol, increases and peaks were established using receiver operating characteristic curves. These and corticosteroid treatment (in n = 112, 65%), among other variables, were examined by multiple logistic regression and Cox proportional hazard regression analyses to find independent predictors of ICU mortality until day 28. ICU mortality until day 28 was 23%. Nonsurvivors had higher SAPS II and SOFA scores. Baseline cortisol levels correlated directly with albumin levels and SAPS II. In the multivariate analyses, a cortisol baseline > 475 nmol/l and cortisol increase < 200 nmol/l predicted mortality, largely dependent on disease severity but independent of albumin levels. Corticosteroid (hydrocortisone) treatment was not associated with an improved outcome, regardless of the ACTH test results. In nonseptic hypotensive ICU patients, a low cortisol/ACTH response and treatment with corticosteroids do not contribute to mortality prediction by severity of disease. The data thus argue against RAI identifiable by cortisol/ACTH testing and necessitating corticosteroid substitution treatment in these patients.