Intensive Care Admission Research Articles

MR-proADM as Prognostic Factor of Outcome in COVID-19 Patients.

Serum mid-regional proadrenomedullin (MR-proADM) has emerged as a marker of organ failure (mainly lungs and kidneys) and poor prognosis in patients admitted to intensive care (IC); some reports also suggest it and other markers, such as Krebs von den Lungen-6 (KL-6) and interleukin-6 (IL-6), as a prognostic biomarker of COVID-19. The aim of the study was to evaluate the performance MR-proADM in hospitalized COVID-19 patients for predicting in-hospital mortality and need for non-invasive or invasive respiratory support. We enrolled 74 patients hospitalized in the COVID Unit of Siena Hospital from March to May 2020, for whom serum samples were available on admission for assay of MR-proADM, KL-6 and IL-6. Demographic data, comorbidities, medical history and clinical laboratory data on days 1-3 of admission and Simplified Acute Physiology Score and Simplified Organ Failure Assessment scores calculated at day 1 were collected retrospectively, as well as mortality and IC admission data. 12 patients died in hospital (16%) and 14 patients were admitted to IC (19%). Serum concentrations of MR-proADM on admission and on day 1 were higher among non-survivors than among survivors (p = 0.015 and p = 0.045, respectively), while those on day 3 were not significantly different. Patients needing respiratory support had higher MR-proADM concentrations on admission than the others (p = 0.046), and those requiring invasive mechanical ventilation had higher MR-proADM on day 1 (p = 0.017). Serum concentrations of KL-6 and IL-6 were significantly higher in non-survivors (p = 0.03 and p = 0.004, respectively). ROC curve analysis showed that serum MR-proADM on day 1 had the best accuracy in predicting death and/or IC admission (AUC = 0.9583, p = 0.0006); the combination of all three biomarkers further improved the accuracy of prediction of death or IC admission (AUC = 0.9793; p = 0.00004). Our data sustain the potential of serum MR-proADM as a reliable prognostic biomarker of hospitalized COVID-19 patients and confirms the utility of the three markers in the management and risk stratification of hospitalized patients. The markers are collected mini-invasively and are quick to analyze and cost-effective.

Outcomes after surgery in patients with and without recent influenza: a nationwide population-based study.

The influence of recent influenza infection on perioperative outcomes is not completely understood. Using Taiwan's National Health Insurance Research Data from 2008 to 2013, we conducted a surgical cohort study, which included 20,544 matched patients with a recent history of influenza and 10,272 matched patients without. The main outcomes were postoperative complications and mortality. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for the complications and for mortality in patients with a history of influenza within 1-14 days or 15-30 days compared with non-influenza controls. Compared with patients who had no influenza, patients with influenza within preoperative days 1-7 had increased risks of postoperative pneumonia (OR 2.22, 95% CI 1.81-2.73), septicemia (OR 1.98, 95% CI 1.70-2.31), acute renal failure (OR 2.10, 95% CI 1.47-3.00), and urinary tract infection (OR 1.45, 95% CI 1.23-1.70). An increased risk of intensive care admission, prolonged length of stay, and higher medical expenditure was noted in patients with history of influenza within 1-14 days. We found that there was an association between influenza within 14 days preoperatively and the increased risk of postoperative complications, particularly with the occurrence of influenza within 7 days prior to surgery.

Effect of lactate levels on extubation time in coronary artery bypass grafting surgery.

In current practice, fast-track protocols are gaining importance in patients undergoing cardiac surgery. For this purpose, besides different application techniques, biomarkers are frequently examined in the peri-operative period. We aimed to examine whether serum lactate levels at different peri-operative intervals had an effect on the extubation time. The patients were analysed in two groups according to the extubation time (early < 6 hours, and late extubation > 6 hours). Individual characteristics, co-existing diseases, blood transfusion, inotropic support, intra-aortic balloon pump, cardiopulmonary bypass time, aortic cross-clamp time, and the serial measurements of serum lactate levels were recorded. Correlations of serial measurements of lactate levels and the peri-operative variables with extubation times were analysed. No significant differences were observed between the groups in terms of co-existing diseases and individual characteristics. However, cardiopulmonary bypass, aortic cross-clamp times and all lactate levels after aortic cross-clamping were found to be significantly different (p = 0.001). A statistically significant correlation was found between the cut-off value of 1.7 for serum lactate levels after aortic-cross clamping (L2); 1.9 for levels after aortic cross-clamp removal (L3); 2.2 for levels after cardiopumonary bypass (L4); 2.1 for levels after intensive care admission (L5); 1.7 for levels after first postoperative hour in the intensive care unit (L6), and 1.8 for the difference between pre-operative levels (L0) and the peak level of lactate in the peri-operative period (ΔL) in predicting extubation time (p < 0.01). We concluded that cardiopulmonary bypass and aortic cross-clamp times, and intra-operative serum lactate levels were important in predicting early extubation after isolated coronary artery bypass graft surgery.

Optimal Dosing and Timing of High-Dose Corticosteroid Therapy in Hospitalized Patients With COVID-19: Study Protocol for a Retrospective Observational Multicenter Study (SELECT).

In hospitalized patients with COVID-19, the dosing and timing of corticosteroids vary widely. Low-dose dexamethasone therapy reduces mortality in patients requiring respiratory support, but it remains unclear how to treat patients when this therapy fails. In critically ill patients, high-dose corticosteroids are often administered as salvage late in the disease course, whereas earlier administration may be more beneficial in preventing disease progression. Previous research has revealed that increased levels of various biomarkers are associated with mortality, and whole blood transcriptome sequencing has the ability to identify host factors predisposing to critical illness in patients with COVID-19. Our goal is to determine the most optimal dosing and timing of corticosteroid therapy and to provide a basis for personalized corticosteroid treatment regimens to reduce morbidity and mortality in hospitalized patients with COVID-19. This is a retrospective, observational, multicenter study that includes adult patients who were hospitalized due to COVID-19 in the Netherlands. We will use the differences in therapeutic strategies between hospitals (per protocol high-dose corticosteroids or not) over time to determine whether high-dose corticosteroids have an effect on the following outcome measures: mechanical ventilation or high-flow nasal cannula therapy, in-hospital mortality, and 28-day survival. We will also explore biomarker profiles in serum and bronchoalveolar lavage fluid and use whole blood transcriptome analysis to determine factors that influence the relationship between high-dose corticosteroids and outcome. Existing databases that contain routinely collected electronic data during ward and intensive care admissions, as well as existing biobanks, will be used. We will apply longitudinal modeling appropriate for each data structure to answer the research questions at hand. As of April 2023, data have been collected for a total of 1500 patients, with data collection anticipated to be completed by December 2023. We expect the first results to be available in early 2024. This study protocol presents a strategy to investigate the effect of high-dose corticosteroids throughout the entire clinical course of hospitalized patients with COVID-19, from hospital admission to the ward or intensive care unit until hospital discharge. Moreover, our exploration of biomarker and gene expression profiles for targeted corticosteroid therapy represents a first step towards personalized COVID-19 corticosteroid treatment. ClinicalTrials.gov NCT05403359; https://clinicaltrials.gov/ct2/show/NCT05403359. DERR1-10.2196/48183.

P-34 The changing risk of hospitalisation, intensive care admission and death due to COVID-19 in patients with gastrointestinal cancer in the UK

P-34 The changing risk of hospitalisation, intensive care admission and death due to COVID-19 in patients with gastrointestinal cancer in the UK

Role of vaccination and anti-SARS-CoV-2 antibodies in the clinical outcome of hospitalized COVID-19 patients

BackgroundAlthough vaccination has considerably reduced the risk of hospitalization and death from COVID19, the impact of vaccination and anti-SARS-CoV-2 antibody status on the outcome of patients who required hospitalization has been poorly investigated. Material and methodsA prospective observational study in 232 patients hospitalized for COVID19 was carried out from October 2021 to January 2022 to evaluate the role on patient outcome of their vaccination and anti-SARS-CoV-2 antibody status and titer, comorbidities, analytical determinations, clinical presentation at admission, treatments and requirements for respiratory support. Cox regression and survival analyzes were performed. The SPSS and “R” programs were used. ResultsPatients with complete vaccination schedule had higher S-protein antibody titers (log10 3.73 [2.83–4.6]UI/ml vs 1.6 [2.99–2.61]UI/ml; p<0.001), lower probability of radiographic worsening (21.6% vs. 35.4%; p=0.005), less likely required high doses of dexamethasone (28.4% vs. 45.4%; p=0.012), high-flow oxygen (20.6% vs. 35.4%; p=0.02), ventilation (13.7% vs, 33.8%; p=0.001) and intensive care admissions (10.8% vs. 32.6%; p<0.001). Remdesivir (HR=0.38; p<0.001) and complete vaccination schedule (HR=0.34; p=0.008) were protective factors. No differences in antibody status were detected between groups (HR=0.58; p=0.219). ConclusionsSARS-CoV-2 vaccination was associated with higher S-protein antibody titers and lower probability of radiological progression, immunomodulators requirement and respiratory support or death. However, vaccination but not antibody titters protected from adverse events pointing a role of immune-protective mechanisms in addition to humoral response.

Predictors of neurocognitive and psychological disorders in children after intensive care admission: A prospective cohort study.

Children admitted in the pediatric intensive care unit (PICU) often deal with long-term morbidities affecting physical, cognitive, emotional, social, and psychiatric symptoms. We aimed to identify the internal and external factors which predict the occurrence of neurocognitive and psychological disorders in survivors at 3 months after PICU discharge. We identified 53 critically ill children, ages 4-18 years old, admitted in PICU for more than 24 h, and survived. We evaluated neurocognitive disorder with Pediatric Cerebral Perfomance Category (PCPC) and psychological disorders with Strengths and Difficulties Questionnaire (SDQ) at the time of PICU discharge and repeated in 3 months afterward. We evaluated the internal and external risk factors related to neurocognitive and psychological disorders in PICU survivors. The internal risk factors were age, gender, family composition, and socioeconomic status. The external risk factors were: surgical intervention, neurological disease, predicted death rate by pediatric index mortality (PIM)-2 score, PICU length of stay (LOS), days of mechanical ventilation, and the number of therapeutic interventions. There were significant improvement in neurocognitive disorders (p < 0.001), peer problems, (p = 0.01), and prosocial behaviors (p = 0.00) in children at 3 months after the PICU discharge. Age of 4-5 years has a significant effect on neurocognitive disorders (p = 0.04), while male gender (p = 0.02), low-social economy, non-intact family composition (p = 0.01), neurological disease (p = 0.04), surgical intervention (p = 0.01), and TISS score (p = 0.00) have a significant effect on psychological disorders in children at 3 months after the PICU discharge. Neurocognitive disorders, peer problems, and prosocial behaviors improved in a few patients 3 months after PICU discharge. Age of 4-5 years was a risk factor of the persisted neurocognitive disorder, whereas male gender, low-social economy, non-intact family composition, neurological disease, surgical intervention, and TISS score were risk factors of persisted psychological disorder at 3 months after PICU.

Relative pandemic severity in Canada and four peer nations during the SARS-CoV-2 pandemic.

National responses to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic have been highly variable. We sought to explore the effectiveness of the Canadian pandemic response up to May 2022 relative to responses in four peer countries with similar political, economic and health systems, and with close historical and cultural ties to Canada. We used reported age-specific mortality data to generate estimates of pandemic mortality standardized to the Canadian population. Age-specific case fatality, hospitalization, and intensive care admission probabilities for the Canadian province of Ontario were applied to estimated deaths, to calculate hospitalizations and intensive care admissions averted by the Canadian response. Health impacts were valued in both monetary terms, and in terms of lost quality-adjusted life years. We estimated that the Canadian pandemic response averted 94,492, 64,306 and 13,641 deaths relative to the responses of the United States, United Kingdom and France, respectively, and more than 480,000 hospitalizations relative to the United States. The United States pandemic response, if applied to Canada, would have resulted in more than $40 billion in economic losses due to healthcare expenditures and lost quality-adjusted life years. In contrast, an Australian pandemic response applied to Canada would have averted over 28,000 additional deaths and averted nearly $9 billion in costs. Canada outperformed several peer countries that aimed for mitigation rather than elimination of SARS-CoV-2 in the first two years of the pandemic, with substantial numbers of lives saved and economic costs averted. However, a comparison with Australia demonstrated that an elimination focus would have saved Canada tens of thousands of lives as well as substantial economic costs.

Risks of neurological and psychiatric sequelae 2 years after hospitalisation or intensive care admission with COVID-19 compared to admissions for other causes

The association between COVID-19 and subsequent neurological and psychiatric disorders is well established. However, two important questions remain unanswered. First, what are the risks in those admitted to intensive care unit (ICU) with COVID-19? Admission to ICU is itself associated with neurological and psychiatric sequelae and it is not clear whether COVID-19 further increases those risks or changes their profile. Second, what are the trajectories of neurological and psychiatric risks in patients admitted to hospital or ICU with COVID-19, and when do the risks subside? We sought to answer these two questions using a retrospective cohort study based on electronic health records (EHR) data from the TriNetX Analytics Network (covering 89 million patients, mostly in the USA). Cohorts of patients admitted to hospital or ICU with COVID-19 were propensity score-matched (for 82 covariates capturing risk factors for COVID-19 and more severe COVID-19 illness) to patients admitted to hospital or ICU (respectively) for any other reason. Matched cohorts were followed for up to two years and the risk of 14 neurological and psychiatric outcomes were compared. A total of 280,173 patients admitted to hospital and 46,573 patients admitted to ICU with COVID-19 were successfully matched to an equal number of patients admitted to hospital or ICU for any other reason. Those hospitalised with COVID-19 were found to be at a greater risk of a range of neurological and psychiatric outcomes including seizure/epilepsy, encephalitis, myoneural junction/muscle disease, Guillain-Barré syndrome (GBS), dementia, cognitive deficits, psychotic disorder, mood and anxiety disorders, but not ischaemic stroke or intracranial haemorrhage. When risks were elevated after COVID-19, most remained so for the whole two years of follow-up (except for mood and anxiety disorders). Risk profiles and trajectories were substantially different among those admitted to ICU: compared to those admitted for any other reasons, those admitted with COVID-19 were at a greater risk of myoneural junction/muscle disease, GBS, cognitive deficits and anxiety disorder, but at a significantly lower risk of ischaemic stroke, intracranial haemorrhage, encephalitis, and mood disorder. When elevated, the risks in those admitted to ICU with COVID-19 were mostly short-lived. In summary, risks of neurological and psychiatric sequelae in patients hospitalised with COVID-19 are wide ranging and long standing whereas those in patients admitted to ICU with COVID-19 are similar to, or lower than, the risks observed post-ICU admission for any other cause. These contrasting risk trajectories are relevant for researchers, clinicians, patients, and policymakers.

Intrapartum Cesarean Section and Perinatal Outcomes after Epidural Analgesia or Remifentanil-PCA in Breech and Twin Deliveries.

Comparative data on the potential impact of various forms of labor analgesia on the mode of delivery and neonatal complications in vaginal deliveries of singleton breech and twin fetuses are lacking. The present study aimed to determine the associations between type of labor analgesia (epidural analgesia (EA) vs. remifentanil patient-controlled analgesia (PCA)) and intrapartum cesarean sections (CS), and maternal and neonatal adverse outcomes in breech and twin vaginal births. A retrospective analysis of planned vaginal breech and twin deliveries at the Department of Perinatology, University Medical Centre Ljubljana, was performed for the period 2013-2021, using data obtained from the Slovenian National Perinatal Information System. The pre-specified outcomes studied were the rates of CS in labor, postpartum hemorrhage, obstetric anal sphincter injury (OASI), an Apgar score of <7 at 5 min after birth, birth asphyxia, and neonatal intensive care admission. A total of 371 deliveries were analyzed, including 127 term breech and 244 twin births. There were no statistically significant nor clinically relevant differences between the EA and remifentanil-PCA groups in any of the outcomes studied. Our findings suggest that both EA and remifentanil-PCA are safe and comparable in terms of labor outcomes in singleton breech and twin deliveries.

Atrial fibrillation and in-hospital mortality in Covid-19 patients

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Wellcome/EPSRC Centre for Medical Engineering Background Although primarily considered a respiratory virus, cardiovascular manifestations have been reported in patients with Covid-19 infection. Atrial fibrillation has been observed as the most common arrhythmia with the prevalence rate reportedly as high as 16.5%(1). Purpose The aim of the study was to establish the incidence of atrial fibrillation in patients hospitalised with Covid-19 and evaluate the relationship between patient characteristics and disease severity with new-onset atrial fibrillation in patients with Covid-19. Methods A single centre, retrospective study of 1241 patients with a confirmed PCR diagnosis of Covid-19 admitted during the 1st wave of the pandemic (1st March to 31st September 2020). Patient demographic data, medical history and clinical outcome data were manually collected. Results The study population comprised of 1241 patients hospitalised with Covid-19. Of these, 94 (7.6%) patients were known to have pre-existing atrial fibrillation. In an unadjusted analysis, in-hospital mortality was twice as likely in patients with pre-existing atrial fibrillation compared to patients with no history of atrial fibrillation (odds ratio (OR): 2.18; 95% CI 1.29-3.59, p=0.002). However, after multi-variable matching for age, sex and CHA2DS2VASc score there was no significant difference between groups (OR: 1.13, 95% CI 0.57-2.21, p=0.732). During their admission, 42 (3.4%) patients developed new-onset atrial fibrillation. New-onset atrial fibrillation was associated with an increased risk of mechanical­­­ ventilation (OR: 4.59, 95% CI 2.34-9.06, p&amp;lt;0.005), intensive care admission (OR: 7.19, 95% CI 3.52-15.61, p&amp;lt;0.005) and in-hospital mortality (OR: 3.58; 95% CI 1.78-7.06, p&amp;lt;0.005). Statistical significance remained after matched analysis (mechanical ventilation OR: 14.00, 95% CI 1.84-106.5, p=0.01; intensive care admission OR: 18, 95% CI 2.40-134.83, p&amp;lt;0.005, in-hospital mortality OR: 2.80, 95% CI 1.01-7.77, p=0.048). New-onset atrial fibrillation was associated with older age (p&amp;lt;0.005), higher CHA2DS2VASc score (p&amp;lt;0.005), elevated white cell count (p=0.046), neutrophil count (p=0.010), C-reactive protein ( p&amp;lt;0.005), ferritin (p=0.020), lower albumin (p&amp;lt;0.005) and eGFR (p=0.013) at the time of hospital admission. No association was found with gender (p=0.683) or race (p=0.080). Conclusion New-onset atrial fibrillation during admission with Covid-19 is associated with both co-morbidity status and markers of disease severity at the time of hospital admission. New-onset atrial fibrillation is associated with elevated in-hospital mortality compared with patients with either pre-existing or no history of atrial fibrillation.

Non-COVID-19 intensive care admissions during the pandemic: a multinational registry-based study

BackgroundThe COVID-19 pandemic resulted in a large number of critical care admissions. While national reports have described the outcomes of patients with COVID-19, there is limited international data of the...

Risk factors for intensive care admission in patients with COVID-19 pneumonia: A retrospective study

BackgroundCoronavirus disease 2019 (COVID-19)-associated mortality is predominantly due to respiratory failure. However, risk factors and predictive models for disease progression in patients with COVID-19 are not consistent across the globe. In this study, we aimed to assess the risk factors associated with intensive care (ICU) admission and mortality in patients with COVID-19 pneumonia. MethodsInformation was retrieved from the database of all patients admitted with COVID-19 pneumonia between March 2020 and July 2020 at a tertiary care center in Saudi Arabia. The patients’ demographic, clinical, laboratory and radiological characteristics were analyzed. ResultsOf 1054 patients admitted with PCR proven COVID-19, 254 patients (24%) with radiological evidence of pneumonia were enrolled. The median age was 55, with 25.6% above 65 years and 55.1% males. The comorbidities included hypertension (45%), diabetes (43%), dyslipidemia (24%), solid organ and bone marrow transplantation (14.5%), malignancy (13.4%), ischemic heart disease (10.6%) and chronic kidney disease (9.4%). The mortality rate was 4.7%, and 22.8% were admitted to the ICU.The risk factors for ICU admission were> 65 years of age (RR: 1.74, CI 95%, 1.10–2.74, p = 0.017), diabetes melitus (RR: 1.66, CI 95% 1.06–2.62, p = 0.028), heart failure (RR: 2.51, CI 95%, 1.28–4.93, p = 0.007), respiratory rate> 25 (RR: 2.75, CI 95%, 1.66–4.55, p < 0.001), upper lobe involvement (RR: 1.68, CI 95%, 1.02–2.77, p = 0.043), and C-reactive protein (CRP)> 140 (RR: 1.89, CI 95%, 1.14–3.13, p = 0.013).The risk factors for mortality were> 65 years of age (RR: 5.82, CI 95%, 1.81–18.68, p = 0.003), upper lobe involvement on chest radiography (RR:4.40, CI 95%, 1.22–15.86, p = 0.016), diffuse chest computed tomography changes (RR: 7.36, CI 95%, 2.31–23.46, p < 0.011), ischemic heart disease (RR: 4.20, CI 95%, 1.36–13.04, p = 0.028), chronic kidney disease (RR: 6.85, CI 95%, 2.35–19.90, p < 0.003), cerebrovascular disease (RR:13.61, CI 95%, 5.01–36.96 p < 0.001), respiratory rate> 25 (RR: 3.94, CI 95%, 1.32–11.78 p = 0.023), oxygen saturation< 90% on admission (RR: 12.19, CI 95%, 3.71–40.01, p < 0.001), thrombocytopenia (RR:4.16, CI 95%, 1.37–12.64, p = 0.013), and elevated troponin (RR: 6.20, CI 95%, 1.73–22.24, p = 0.003). ConclusionsIn this study, nearly a quarter of the patients with COVID-19 pneumonia required intensive care. We identified several risk factors associated with ICU admission and mortality that may be useful for predicting, triaging, and managing COVID-19 pneumonia patients. However, these findings need to be validated prospectively.

Trends in Cardiovascular Surgery in South Korea: A Nationwide Cohort Study from 2010 to 2019

We aimed to investigate mortality and its associated factors in cardiovascular surgery-associated intensive care unit (ICU) admissions in South Korea from 2010 to 2019. Population-based cohort study. Data from the National Health Insurance Service database in South Korea were used in this study. All adult patients admitted to the ICU associated with cardiovascular surgery in South Korea between January 1, 2010 and December 31, 2019 were analyzed. None. A total of 62,794 ICU admissions associated with cardiovascular surgery were included in the analysis (median value of age: 65 years; 58.0% men). This included patients who underwent coronary artery bypass grafting (CABG) only (n=10,704), valve-only surgery (n=35,812), CABG+valve surgery (n=3,230), aortic procedures (n=7,968), and others (n=5,080). The number of cardiovascular surgeries associated with ICU admissions was 4,409 in 2010, which gradually increased to 10,366 in 2019. The aortic procedure group had the highest 1-year mortality rate after cardiovascular surgery (15.7%), followed by the CABG+valve (13.2%), others (11.5%), CABG-only (9.5%), and valve-only (8.7%) groups. Invasive life support procedures during the ICU stay and hospital admission through the emergency room were potential risk factors for 1-year mortality after cardiovascular surgery. Cardiovascular surgery-associated intensive care admissions gradually increased from 2010 to 2019 in South Korea. Among these patients, the highest 1-year mortality rate was observed in the aortic procedures group, followed by the CABG+valve, others, CABG-only, and valve-only groups.

Psychiatric patients' intensive care admission characteristics, weaning from mechanical ventilation and sedative drug use: A single center retrospective case-control study

PurposeTo describe the characteristics, treatment and outcome, in particular weaning from mechanical ventilation (MV), of critically ill Patients with prior psychiatric conditions (PPC). MethodsSingle center, 6-year, retrospective study comparing critically ill PPC to randomly sex and age matched cohort without PPC (1:1 ratio). Main outcome measure- adjusted mortality rates. Secondary outcome measures- unadjusted mortality, rates of MV, extubation failure and amount/dose of pre-extubation sedatives/analgesics. ResultsIncluded were 214 patients per group. PPC adjusted mortality rates were higher in the ICU (14.0% vs 4.7%; OR 3.058 [95%CI 1.380, 6.774]; p = 0.006) and in-hospital (26.6% vs 13.1%; OR 2.639 [95% CI 1.496, 4.655]; p = 0.001). PPC had higher MV rates (63.6% vs 51.4%; p = 0.011). These patients were more likely to have more than two weaning attempts (29.4% vs 10.9%; p < 0.001), more commonly treated with >2 sedative drugs in the 48-h pre-extubation (39.2% vs 23.3%; p = 0.026) and received more propofol in the 24-h pre-extubation. PPC were more likely to self-extubate (9.6% vs 0.9%; p = 0.004) and had lower likelihood of success in planned extubations (50.0% vs 76.4%; p < 0.001). ConclusionCritically ill PPC had higher mortality rates than their matched counterparts. They also had higher MV rates and were more difficult to wean.

Evaluation of evolving sepsis screening criteria in discriminating suspected sepsis and mortality among adult patients admitted to the intensive care unit

BackgroundInstitutions struggle with successful use of sepsis alerts within electronic health records. ObjectiveTest the association of sepsis screening measurement criteria in discrimination of mortality and detection of sepsis in a large dataset. DesignRetrospective, cohort study using a large United States (U.S.) intensive care database. The Institutional Review Board exempt status was obtained from Kansas University Medical Center Human Research Protection Program (10-1-2015). Setting334 U.S. hospitals participating in the eICU Research Institute. ParticipantsNine hundred twelve thousand five hundred and nine adult intensive care admissions from 183 hospitals. MethodsExposures included: systemic inflammatory response syndrome criteria ≥ 2 (Sepsis-1); systemic inflammatory response syndrome criteria with organ failure criteria ≥ 3.5 points (Sepsis-2); and sepsis-related organ failure assessment score ≥ 2 and quick score ≥ 2 (Sepsis-3). Discrimination of outcomes was determined with/without (adjusted/unadjusted) baseline risk exposure to a model. The receiver operating characteristic curve (AUROC) and odds ratios (ORs) for each decile of baseline risk of sepsis or death were assessed. ResultsWithin the eligible cohort of 912,509, a total of 86,219 (9.4 %) patients did not survive their hospital stay and 186,870 (20.5 %) met the definition of suspected sepsis. For suspected sepsis discrimination, Sepsis-2 (unadjusted AUROC 0.67, 99 % CI: 0.66–0.67 and adjusted AUROC 0.77, 99 % CI: 0.77–0.77) outperformed Sepsis-3 (SOFA unadjusted AUROC 0.61, 99 % CI: 0.61–0.61 and adjusted AUROC 0.74, 99 % CI: 0.74–0.74) (qSOFA unadjusted AUROC 0.59, 99 % CI: 0.59–0.60 and adjusted AUROC 0.73, 99 % CI: 0.73–0.73). Sepsis-2 also outperformed Sepsis-1 (unadjusted AUROC 0.58, 99 % CI: 0.58–0.58 and adjusted AUROC 0.73, 99 % CI: 0.73–0.73). In between differences of AUROCs were statistically significantly different. Sepsis-2 ORs were higher for the outcome of suspected sepsis when considering deciles of risk than the other measurement systems. Conclusions and relevanceSepsis-2 outperformed other systems in suspected sepsis detection and was comparable to SOFA in prognostic accuracy of mortality in adult intensive care patients.

High-flow oxygen therapy in moderate to severe bronchiolitis: a randomised controlled trial

Background and objectiveHigh-flow (HF) oxygen therapy is being used increasingly in infants with bronchiolitis, despite lack of convincing evidence of its superiority over low flow (LF). We aimed to compare...

Effect of progesterone on preventing preterm birth and adverse perinatal outcomes in women in the risk group: A prospective clinical trial

Background and Objective: Preterm labor is a significant reason for perinatal mortality and morbidity. This study was conducted to determine the effect of two regimens of progesterone to avoid preterm labor and the adverse perinatal outcomes in the two groups. Methods: A prospective clinical trial was performed in Maternity Teaching Hospital and Hawler Private Hospital in Erbil city, Kurdistan region, Iraq over a one-year period from 1 May 2019 until 1 May 2020. The study sample was 200 pregnant women with a short cervix and a risk of preterm birth; the sample was divided into two groups. Group I of 100 pregnant women received 400 mg progesterone vaginally once daily, and group II of 100 pregnant women received it twice daily, started from 16 weeks of gestation up to the time of delivery in both groups. Results: The rate of term pregnancy (? 37 weeks) was 87% among women in group II and 55% in women in group I. Accordingly, the rate of neonatal intensive care admission was significantly higher in group I than in group II (30% and 11%, respectively). The rate of respiratory distress syndrome was also significantly higher in group I (31%) than in group II (7%). Conclusion: The administration of progesterone 400 mg vaginally twice a day appears to be more effective than progesterone 400 mg vaginally once a day in preventing preterm birth and reducing the risk of adverse neonatal complications.

Impact of an emergency department rapid response system on inpatient clinical deterioration: A controlled pre-post study

AimTo determine the impact implementation of Emergency Department Clinical Emergency Response System (EDCERS) on inpatient deterioration events and identify contributing causal factors. MethodsEDCERS was implemented in an Australian regional hospital, integrating a single parameter track and trigger criteria for escalation of care, and emergency, specialty and critical care clinician response to patient deterioration. In this controlled pre-post study, electronic medical records of patients who experienced a deterioration event (rapid response call, cardiac arrest or unplanned intensive care admission) on the ward within 72 h of admission from the emergency department (ED) were reviewed. Causal factors contributing to the deteriorating event were assessed using a validated human factors framework. ResultsImplementation of EDCERS reduced the number of inpatient deterioration events within 72 h of emergency admission with failure or delayed response to ED patient deterioration as a causal factor. There was no change in the overall rate of inpatient deterioration events. ConclusionThis study supports wider implementation of rapid response systems in the ED to improve management of deteriorating patients. Tailored implementation strategies should be used to achieve successful and sustainable uptake of ED rapid response systems and improve outcomes in deteriorating patients.

Invasive group A streptococcal disease in Hawke's Bay, New Zealand: epidemiology, manifestations and impact.

To describe the epidemiology, clinical features and healthcare impact of invasive group A streptococcal (iGAS) disease in Hawke's Bay from 2016 to 2021, to inform public health efforts. The case definition of iGAS for this study was isolation of group A streptococcus (GAS) from blood culture. "Severe iGAS" included cases that required intensive care admission or died within 60 days. Cases were identified retrospectively from the Te Whatu Ora Te Matau a Māui Hawke's Bay laboratory database. Clinical data were obtained from inpatient electronic health records. A total of 93 cases of iGAS were identified in Hawke's Bay during the 6-year study period. The overall age-standardised incidence of iGAS was 5.6 per 100,000 (95%CI 4.1-7.4). The incidence was significantly higher among people of Pacific, Māori and Asian ethnicities than European/Other ethnicities, and higher in areas of socio-economic disadvantage. Skin infections were the most common source (70% of cases). Thirty-seven cases (41%) were classified as severe, including 11 deaths (12% case fatality rate). Further action is required to address inequities in social determinants of skin health in Hawke's Bay. Mandatory national notification of iGAS would provide opportunity for improved surveillance of GAS-related disease, and consideration of a public health response to iGAS disease in New Zealand.