In-intensive Care Research Articles

PP308 Topic: AS05–End of Life: Palliative Care/Organ Donation/Ethics/Spirituality & Wellness/Other: BARRIERS TO PROVIDING PEDIATRIC PALLIATIVE CARE IN INTENSIVE CARE UNITS IN MEXICO

PP308 Topic: AS05–End of Life: Palliative Care/Organ Donation/Ethics/Spirituality & Wellness/Other: BARRIERS TO PROVIDING PEDIATRIC PALLIATIVE CARE IN INTENSIVE CARE UNITS IN MEXICO

PP134 Topic: AS14–Infections: Sepsis and Septic Shock/Antimicrobial Stewardship/Tropical and Parasite Infections/Other: PREDICTORS OF MORTALITY IN IMMUNOCOMPROMISED CHILDREN WITH SEVERE SEPSIS AND SEPTIC SHOCK IN INTENSIVE CARE UNIT–MULTICENTER STUDY IN SAUDI ARABIA

PP134 Topic: AS14–Infections: Sepsis and Septic Shock/Antimicrobial Stewardship/Tropical and Parasite Infections/Other: PREDICTORS OF MORTALITY IN IMMUNOCOMPROMISED CHILDREN WITH SEVERE SEPSIS AND SEPTIC SHOCK IN INTENSIVE CARE UNIT–MULTICENTER STUDY IN SAUDI ARABIA

Clinical and cost avoidance benefits of integrating pharmacist inintensive care unit

Clinical and cost avoidance benefits of integrating pharmacist inintensive care unit

CRITICAL NOREPINEPHRINE DOSE TO PREDICT EARLY MORTALITY DURING CIRCULATORY SHOCK IN INTENSIVE CARE: A RETROSPECTIVE STUDY IN 3423 ICU PATIENTS OVER 4-YEAR PERIOD.

Introduction: The maximal norepinephrine (NE) dose >1 μg/kg/min during circulatory shock apparently is associated with higher mortality, but this threshold needs confirmation. This study aimed at investigating whether NE infusion at a dose >1 μg/kg/min could predict early intensive care unit (ICU) mortality (first 5 days). The secondary objective was to assess the day-by-day relationship between NE dose during the first 4 days of ICU stay and subsequent mortality. Methods: We conducted a retrospective analysis of data from ICU patients receiving NE for circulatory shock at the Nimes University Hospital (France) from January 2016 to December 2019. Results: A total of 5,735 patients were admitted, 3,693 were screened, and 3,423 were analyzed. NE infusion at a dose >1 μg/kg/min was associated with day-5 mortality (hazards ratio: 7.40, P < 0.0001). The area under the receiver operating characteristic was 0.79 to predict day-5 mortality in ICU for maximal NE >1 μg/kg/min. The calculated threshold of 1.13 μg/kg/min for maximal NE was the best prognostic value (sensitivity: 67%, specificity: 80%, positive predictive value: 45%). When the 1.2 μg/kg/min threshold was crossed either on the first, second, third, or fourth day of ICU stay, the probability of subsequent death was 47%, 49%, 60%, and 40%, respectively. Along the first 4 days of ICU stay, the risk of death increased with increasing NE infusion dose. Conclusions: An NE infusion rate >1.13 μg/kg/min predicts day-5 mortality in ICU patients with circulatory shock. The time to reach maximal NE infusion rate was shorter in survivors than in nonsurvivors.

Explainable Deep Contrastive Federated Learning System for Early Prediction of Clinical Status in Intensive Care Unit

Explainable Deep Contrastive Federated Learning System for Early Prediction of Clinical Status in Intensive Care Unit

THE INTERSECTION OF TECHNOLOGY AND PATIENT CARE IN ANESTHESIA AND INTENSIVE CARE: A RESEARCH SYNTHESIS

THE INTERSECTION OF TECHNOLOGY AND PATIENT CARE IN ANESTHESIA AND INTENSIVE CARE: A RESEARCH SYNTHESIS

Machine learning-based prediction of in-ICU mortality in pneumonia patients

Conventional severity-of-illness scoring systems have shown suboptimal performance for predicting in-intensive care unit (ICU) mortality in patients with severe pneumonia. This study aimed to develop and validate machine learning (ML) models for mortality prediction in patients with severe pneumonia. This retrospective study evaluated patients admitted to the ICU for severe pneumonia between January 2016 and December 2021. The predictive performance was analyzed by comparing the area under the receiver operating characteristic curve (AU-ROC) of ML models to that of conventional severity-of-illness scoring systems. Three ML models were evaluated: (1) logistic regression with L2 regularization, (2) gradient-boosted decision tree (LightGBM), and (3) multilayer perceptron (MLP). Among the 816 pneumonia patients included, 223 (27.3%) patients died. All ML models significantly outperformed the Simplified Acute Physiology Score II (AU-ROC: 0.650 [0.584–0.716] vs 0.820 [0.771–0.869] for logistic regression vs 0.827 [0.777–0.876] for LightGBM 0.838 [0.791–0.884] for MLP; P < 0.001). In the analysis for NRI, the LightGBM and MLP models showed superior reclassification compared with the logistic regression model in predicting in-ICU mortality in all length of stay in the ICU subgroups; all age subgroups; all subgroups with any APACHE II score, PaO2/FiO2 ratio < 200; all subgroups with or without history of respiratory disease; with or without history of CVA or dementia; treatment with mechanical ventilation, and use of inotropic agents. In conclusion, the ML models have excellent performance in predicting in-ICU mortality in patients with severe pneumonia. Moreover, this study highlights the potential advantages of selecting individual ML models for predicting in-ICU mortality in different subgroups.

HEART RATE VARIABILITY PARAMETERS WERE NOT ASSOCIATED WITH 30-DAY ALL-CAUSE MORTALITY IN INTENSIVE CARE UNIT PATIENTS WITH OR WITHOUT ATRIAL FIBRILLATION: A RETROSPECTIVE STUDY OF THE MIMIC-IV DATABASE.

Objective: Our study aims to evaluate the association between heart rate variability (HRV) and short- and long-term prognosis in patients admitted to intensive care unit (ICU). Methods and Results: Adult patients continuously monitored for over 24 h in ICUs from the the American Medical Information Mart for Intensive Care (MIMIC)-IV Waveform Database were recruited in our study. Twenty HRV-related variables (8 time domain, 6 frequency domain, and 6 nonlinear variables) were calculated based on RR intervals. The association between HRV and all-cause mortality was assessed. Ninety-three patients met the inclusion criteria and were classified into atrial fibrillation (AF) and sinus rhythm (SR) groups, which were further divided into 30-day survivor group and nonsurvivor\groups based on their survival status. The 30-day all-cause mortality rates in AF and SR groups were 36.3% and 14.6%, respectively. All the time domain, frequency domain, and nonlinear HRV parameters did not differ significantly between survivors and nonsurvivors with or without AF (all P > 0.05). Presence of renal failure, malignancy, and elevated blood urea nitrogen level were associated with increased 30-day all-cause mortality in SR patients, while presence of sepsis, infection, higher platelet count, and magnesium level were associated with increased 30-day all-cause mortality in AF patients. Conclusions: Heart rate variability variables were not associated with increased 30-day all-cause mortality in ICU patients with or without AF.

Right ventricle dysfunction does not predict mortality in patients with SARS-CoV-2-related acute respiratory distress syndrome on extracorporeal membrane oxygenation support

The prognostic role of right ventricle dilatation and dysfunction (RVDD) has not been elucidated in patients with coronavirus disease (COVID)-related respiratory failure refractory to standard treatment needing extracorporeal membrane oxygenation (ECMO) support. To assess whether pre veno-venous (VV) ECMO RVDD were related to in-intensive care unit (ICU) mortality. We enrolled 61 patients with COVID-related acute respiratory distress syndrome refractory to conventional treatment submitted to VV ECMO and consecutively admitted to our ICU (an ECMO referral center) from 31th March 2020 to 31th August 2021. An echocardiographic exam was performed immediately before VV ECMO implantation. Males were prevalent (73.8%) and patients with a body mass index > 30 kg/m2 were the majority (46/61, 75%). The overall in-ICU mortality rate was 54.1% (33/61). RVDD was detectable in more than half of the population (34/61, 55.7%) and associated with higher simplified organ functional assessment (SOFA) values (P = 0.029) and a longer mechanical ventilation duration prior to ECMO support (P = 0.046). Renal replacement therapy was more frequently needed in RVDD patients (P = 0.002). A higher in-ICU mortality (P = 0.024) was observed in RVDD patients. No echo variables were independent predictors of in-ICU death. In patients with COVID-related respiratory failure on ECMO support, RVDD (dilatation and dysfunction) is a common finding and identifies a subset of patients characterized by a more severe disease (as indicated by higher SOFA values and need of renal replacement therapy) and by a higher in-ICU mortality. RVDD (also when considered separately) did not result independently associated with in-ICU mortality in these patients.

EARLY INITIATION OF RENAL REPLACEMENT THERAPY IN INTENSIVE CARE UNIT PATIENTS WITH BOTH ACUTE RESPIRATORY DISTRESS SYNDROME AND SEPSIS WITH OR WITHOUT RENAL FAILURE: A RETROSPECTIVE COHORT STUDY BASED ON PROPENSITY SCORE MATCHING.

Background: It is unknown whether early renal replacement therapy (RRT) initiation strategy in intensive care unit (ICU) patients with both acute respiratory distress syndrome (ARDS) and sepsis with or without renal failure is clinically beneficial. Patients and methods: A total of 818 patients with both ARDS and sepsis admitted to the ICU of Tianjin Medical University General Hospital were included in the analysis. Early RRT was defined as initiating the RRT strategy within 24 h of admission. The relationship between early RRT and clinical outcomes, including primary (30-day mortality) and secondary (90-day mortality, serum creatinine, Pa o2 /Fi o2 , duration of invasive mechanical ventilation, cumulative fluid output, and cumulative fluid balance) outcomes, was compared using propensity score matching (PSM). Results: A total of 277 patients (33.9% of the total population) underwent an early RRT initiation strategy before PSM. After PSM, a cohort of 147 patients with early RRT and 147 patients without early RRT with matched baseline characteristics (including serum creatinine at admission) were constructed. Early RRT was not significantly associated with 30- (hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.85-1.85; P = 0.258) or 90-day mortality (HR, 1.30; 95% CI, 0.91-1.87, P = 0.150). At each time point within 72 h after admission, there was no significant difference in serum creatinine, Pa o2 /Fi o2 and duration of mechanical ventilation between the early and the no early RRT groups. Early RRT significantly increased total output at all time points within 72 h of admission and reached a statistically significant negative fluid balance at 48 h. Conclusions: Early RRT initiation strategies had no statistically significant survival benefit in ICU patients with both ARDS and sepsis, with or without renal failure, nor did they significantly improve serum creatinine and oxygenation or shorten the duration of mechanical ventilation. The use and timing of RRT in such patients should be thoroughly investigated.

EARLY PREDICTIVE VALUE OF PRESEPSIN FOR SECONDARY SEPSIS AND MORTALITY IN INTENSIVE CARE UNIT PATIENTS WITH SEVERE ACUTE PANCREATITIS.

Purpose : Sepsis is the leading cause of death in patients with severe acute pancreatitis (SAP) in the intensive care unit (ICU). Early prediction of sepsis secondary to SAP developed in the late phase and of related mortality can enable appropriate treatment and improve outcomes. This study was conducted to evaluate the predictive value of presepsin in ICU patients with SAP at the early stage and compared it with established blood markers and scoring systems. Methods : This retrospective study enrolled 48 septic patients and 53 nonseptic patients admitted to ICU with SAP. Presepsin and other blood markers (procalcitonin, C-reactive protein, IL-6, white blood cell, and serum creatinine) on days 1, 3, and 7 after enrollment as well as scoring systems were assessed to predict secondary sepsis. Outcomes were evaluated at ICU discharge and on days 28 and 90. Results : Presepsin levels (on days 1, 3, and 7) were significantly higher in septic patients than in nonseptic patients. Presepsin levels showed an increasing trend over time in both sepsis and nonsepsis groups, but concentrations increased more rapidly in the sepsis group than in the nonsepsis group. Among the analyzed biomarkers, presepsin was the only blood marker independently associated with sepsis secondary to SAP on days 3 and 7, and presepsin on day 3 was independently associated with mortality at ICU discharge and on days 28 and 90. It showed similar or even better predictive accuracy for both secondary sepsis and mortality than procalcitonin and Sequential Organ Failure Assessment score. Conclusion : Presepsin could be a valuable early predictor of secondary sepsis and mortality in patients admitted to the ICU with SAP and may serve as an indicator for early risk stratification.

Continuing Education in Plastic, Reconstructive and Aesthetic Surgery in Europe and its Relevance for Patient Safety

Dear Readers,In this issue, the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) has dealt with the quality of continuing education in plastic surgery in Europe in the form of an “ESPRAS Survey”. An overview of the high quality criteria that are necessary in all countries in order to successfully complete specialist training in plastic and aesthetic surgery is summarised clearly and in detail. In Europe, as in Germany, specialist training generally includes training in all body regions, a training period of about 6 years, a rotation in intensive care units for the care of critically ill patients as well as surgical catalogues and specialist examinations.

Candida auris: outbreak fungal pathogen in COVID-19 pandemic: a systematic review and meta-analysis.

Candida auris (C. auris) is the first fungal pathogen considered a global health threat. Because, C. auris is associated with multidrug resistance and associated diseases such as diabetes, sepsis, lung and kidney disease. This study investigated the prevalence and mortality of C. auris infection during Covid-19 pandemic. Databases were searched for peer-reviewed articles published in the English language up to Jan 18, 2022. Heterogeneity across studies was evaluated using Cochrane's Q test and the I2 index. The pooled point prevalences and their corresponding 95% confidence intervals (CIs) were estimated usingthe random-effects model. In our meta-analysis, 11 eligible articles were included. The total pooled prevalence estimation of C. auris infection among COVID-19 patients was 13% (95% CI: 8%, 19%). The estimated pooled mortality rate of C. auris infection was 37% (95% CI: 15%, 61%). In terms of specific conditions, the pooled risk of mortality was higher in people with diabetes 65% (95% CI: 0.45%, 83%), in cases with >21 days admission inintensive care unit (ICU) 44% (95% CI: 21%, 0.68%), and after receiving steroids 43% (95% CI: 18%, 69%). Our study highlights the high prevalence rate of C. auris infection, particularly among people with a history of metabolic disorders.

Amniotic fluid embolism rescued by venoarterial extracorporeal membrane oxygenation

BackgroundAmniotic fluid embolism (AFE) is a rare but often catastrophic complication of pregnancy that leads to cardiopulmonary dysfunction and severe disseminated intravascular coagulopathy (DIC). Although few case reports have reported successful use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with AFE, concerns can be raised about the increased bleeding risks with that device.MethodsThis study included patients with AFE rescued by VA-ECMO hospitalized in two high ECMO volume centers between August 2008 and February 2021. Clinical characteristics, critical care management, in-intensive care unit (ICU) complications, and hospital outcomes were collected. ICU survivors were assessed for health-related quality of life (HRQL) in May 2021.ResultsDuring that 13-year study period, VA-ECMO was initiated in 54 parturient women in two high ECMO volume centers. Among that population, 10 patients with AFE [median (range) age 33 (24–40), SAPS II at 69 (56–81)] who fulfilled our diagnosis criteria were treated with VA-ECMO. Pregnancy evolved for 36 (30–41) weeks. Seven patients had a cardiac arrest before ECMO and two were cannulated under cardiopulmonary resuscitation. Pre-ECMO hemodynamic was severely impaired with an inotrope score at 370 (55–1530) μg/kg/min, a severe left ventricular ejection fraction measured at 14 (0–40)%, and lactate at 12 (2–30) mmol/L. 70% of these patients were alive at hospital discharge despite an extreme pre-ECMO severity and massive blood product transfusion. However, HRQL was lower than age-matched controls and still profoundly impaired in the role-physical, bodily pain, and general health components after a median of 44 months follow-up.ConclusionIn this rare per-delivery complication, our results support the use of VA-ECMO despite intense DIC and ongoing bleeding. Future studies should focus on customized, patient-centered, rehabilitation programs that could lead to improved HRQL in this population.

THE EFFECT OF COVID-19 VACCINES ON PNEUMOTHORAX IN GERIATRIC PATIENTS HOSPİTALIZED IN INTENSIVE CARE UNIT DUE TO COVID-19.

In our study, we examined the effect of COVID-19 vaccination on the incidence of pneumothorax in intensive care patients over age 65. COVID-19 intensive care patients that presented to our department between April 2020 and May 2021 during the COVID-19 pandemic were evaluated retrospectively. Patients were divided into two main groups, i.e., before and after the vaccination period. Patients were evaluated retrospectively for the following parameters: gender, age, side of pneumothorax, mortality, discharge, comorbidity, and additional pleural complications. The total number of patients was 87, i.e., 66 patients before vaccination and 21 patients after vaccination. When patients in the pre- and post-vaccination period were compared, there was a significant difference in the incidence of pneumothorax between the two groups (p<0.05). Pneumothorax was less common after vaccination. When patients with pneumothorax and tube thoracostomy were evaluated according to pre- and post-vaccination mortality, mortality was significantly higher (89%) in the pre-vaccination period (p<0.05). We consider that COVID-19 vaccines used in patients aged over 65 reduced the incidence of pleural complications, especially pneumothorax. We think that mortality due to pneumothorax in patients over 65 years of age was lower during the vaccination period. In addition, we think that bilateral pneumothorax was more common in the non-vaccinated period. As a result, we think that life-threatening pneumothorax and similar complications could be reduced by increasing the number of vaccines made in the COVID-19 pandemic and spreading it around the world.

Psychiatric management of Patients in intensive care units.

Psychiatric management of Patients in intensive care units.

Effect of Tracheostomy Care Guidelines on Internship Nurses Students' Performance and Confidence Level

Background:Improving tracheostomy care and providing a safe practice is achieved by combining the best experiences, skills, knowledge, providing the best teaching methods and latest advances in its management, and evaluating the outcome. Study Aim: This study aimed to assess and evaluate the effect of tracheostomy care guidelines on internship nurses' students' performance and confidence level. Methods: A quasi-experimental design was used. The study was conducted in Intensive care units affiliated to Al-Ameer Abd Elaziz hospital and Al-Borg Hospital, Arar, Saudi Arabia. The sample consisted of 40 internships nurses' students. Self-administered nurses’ knowledge about tracheostomy questionnaire, internship nurses' students' performance observational checklist and confidence level five-point Likert scale. Results: Post-intervention of tracheostomy care guidelines most of the internship nurses' students had good knowledge in tracheostomy care and most of them had a satisfactory level of practices. There were highly statistically significant differences between pre-and post-educational guidelines for internship nurses' students' knowledge, practice, and confidence level regarding tracheostomy care. Conclusion: Educational guidelines were helpful in the improvement of the internship nurses' students’ knowledge, practice, and confidence level regarding tracheostomy care Recommendations: Periodic educational training programs for internship nurses' students regarding tracheostomy care which based on the best practice guidelines

A Review of the Tolerance and Adequacy of Enteral Nutrition Administered in the Prone Position in Critically Ill Patients Receiving Mechanical Ventilation

ObjectivesDuring the coronavirus 2019 (COVID-19) pandemic, more patients require enteral nutrition (EN) while mechanically ventilated in the prone position (PP). Prone positioning may improve oxygenation in patients receiving mechanical ventilation; however, it is unclear how it affects EN adequacy and tolerance. This review explored how EN delivered in the PP impacts EN tolerance (vomiting, diarrhea, abdominal distention, or aspiration pneumonia) and adequacy (meeting estimated energy and protein requirements) in critically ill adults receiving mechanical ventilation.MethodsA literature search was conducted in PubMed, CINAHL, Academic Search Premier, and Cochrane Library for English-language studies exploring EN administered in the PP published between 2000–2020. Studies that met inclusion criteria enrolled adult patients inintensive care units with acute respiratory distress syndrome or other respiratory conditions requiring mechanical ventilation, were cohort studies with ≥5 patients per study group, and had a dropout rate <20%. Studies were excluded if patients received only parenteral nutrition.ResultsOf 45 studies, 4 met inclusion criteria. Three were prospective cohorts and 1 was a before-after study. When comparing EN tolerance in the PP and supine positions, 1 study found no difference in diarrhea occurrence, 2 studies found no difference in the rate of vomiting, and 1 study found significantly higher rates of vomiting while in the PP. For feeding adequacy, 2 studies found no difference in the % of calories received when administered in prone or supine positions, while 1 study found patients in the PP received significantly less EN volume than patients in the supine position. One study concluded that prophylactic prokinetic agent use and head elevation while prone resulted in larger EN volumes delivered with reduced vomiting risk.ConclusionsThese results suggest the adequacy of EN delivered in the PP is comparable to the supine position and PP does not substantially increase vomiting or diarrhea risk. Prone positioning should not be considered an immediate contraindication to EN for adults receiving mechanical ventilation. These findings may apply to the nutritional management of critically ill mechanically ventilated adults with COVID-19.Funding SourcesNone

Clinical impact of type 2 diabetes mellitus on outcomes after one-lung ventilation during thoracic surgery: a retrospective cohort study.

The preoperative presence of diabetes mellitus (DM) has been recently demonstrated to be a risk factor for adverse events after thoracic surgery. However, the specific effects of presence of DM preoperatively on thoracic surgery is not known. This study aimed to investigate the association between preoperative DM and clinical outcomes and the short-term survival rates after thoracic surgery. In this retrospective, observational, and matched-pair analysis study, patients receiving thoracic surgery from a tertiary university hospital in 2 consecutive years were grouped as either type 2 DM (T2DM) or controlled within the first 24 hours after surgery. Multivariate Cox regression was conducted to investigate the impact of T2DM within the first 24 hours of admission on in-intensive care unit (ICU) and hospital survival. Among the included thoracic patients, 41 (8.4%) had T2DM and 450 (91.6%) did not have T2DM. In the single-factor analyses, T2DM patients were shown to have a higher preoperative white blood cells (WBCs) count, increased release of immunoglobulin A, complement C3 and C4, impaired kidney function with high level of urea, and low expression of alanine aminotransferase (ALT) and monoamine oxidase (MAO). In multivariate analyses, the preoperative urea level was associated with a low-grade risk of dying for the ICU survival time. In contrast, preoperative complement C3 level favored a positive contribution in-ICU survival. Besides the complement C3 level, immunoglobulin A level remained a positive contribution in regression models of hospital survival. Pre-admission T2DM was not associated with an increased in-ICU and hospital mortality among patients with thoracic surgery. Furthermore, they were accompanied by impaired kidney function, activated inflammation and liver function.

Effect of renal replacement therapy modalities on renal recovery and mortality for acute kidney injury: A PRISMA-compliant systematic review and meta-analysis.

Previous investigations showed inconsistent results for comparison in renal recovery, in-hospital, and in-intensive care unit (ICU) mortalities between acute kidney injury (AKI) patients treated with continuous renal replacement therapy (CRRT) and some kinds of intermittent renal replacement therapies (IRRTs). We systematically searched for articles published in the databases (PubMed, Web of Science, EMBASE, Medline, and Google Scholar) until June 2019. We made all statistical analysis using STATA 12.0 software. In the present meta-analysis, relative risks with 95% confidence intervals were calculated for binary outcomes (renal recovery status or mortality). The present study indicated no significant differences in renal recovery, in-hospital mortality, and in-ICU mortality between AKI patients given CRRT and those given sustained low-efficiency dialysis (SLED). Additionally, the study showed no significant difference in in-hospital mortality between AKI patients given CRRT and those given intermittent hemodialysis (IHD), whereas elevated in-ICU mortality was detected in AKI patients given CRRT, compared to those given IHD. The three modalities (CRRT, IHD, and SLED) have their own advantages and disadvantages. More rigorous trials design with large cohort should be made to explore the differences in renal recovery, in-hospital, and in-ICU mortalities between different kinds of RRTs.