Intensive Care Unit Population Research Articles

Type of underlying fracture after the surgical treatment of geriatric trauma patients has no effect on mortality during intensive care treatment.

Due to demographic change, the number of geriatric patients is still rising. Although hip fractures are the subject of current research, little is known about the remaining geriatric trauma entities. The aim of this study was to collect data of the age-related traumatological intensive care unit (ICU) population, its underlying diagnosis, and the influence on mortality and length of stay in the ICU. Geriatric trauma patients (aged ≥65 years) treated postoperatively in our surgical ICU were included in this retrospective observational study covering the period 2013-2017. In addition to the underlying fracture entities, patient characteristics, such as age, sex, Charlson Comorbidity Index, length of stay and mortality, were collected to identify possible independent predictive factors for mortality in the ICU using multivariate analysis. During the observation period, 805 (60.5%) patients met the inclusion criteria. 47.6% of the patients suffered from a proximal femoral fracture. The total mortality rate during the stay in the ICU was 7.5%. Significant predictive factors for mortality in the ICU were Charlson Comorbidity Index (P < 0.001) and length of stay (P < 0.001). The different fracture types themselves were not a significant risk factor for mortality (P = 0.862). Patients with proximal femoral fractures account for approximately half of the patients in intensive care. The mortality rate of these patients is no higher than that in geriatric trauma patients with other fractures. The progression is essentially influenced by the patient's comorbidities. Nowadays, the focus shifts from trauma care to the therapy of concomitant diseases. Nevertheless, this cohort, when adequately treated, shows a comparatively low mortality rate. Geriatr Gerontol Int 2020; 20: 1120-1125.

Nutritional Management of the Critically Ill Obese Patient

Purpose of review: The prevalence of obesity in Malaysia has increased four folds over the past two decades. Epidemiologic studies suggest that there are increased numbers of overweight and obese patients admitted to the intensive care unit (ICU). Increased morbidity and mortality along with longer duration of ICU stay and time on mechanical ventilator have been shown to be associated with this particular body habitus. This review will discuss the recent findings and evidence-based approaches to provide nutrition therapy for this ICU population. Recent findings: Nutrition therapy plays a vital role in improving their outcome; however, clinicians need knowledge of certain obstacles that are unique to obese patients. Nutrition assessment should be comprehensive, because the presence of malnutrition is always underestimated. The increased basal insulin level suppresses lipid mobilisation but increases protein breakdown in obesity, thus leading to protein malnutrition. Large variations in body composition among the obese make estimation of caloric requirements very difficult. There is no consensus as to which predictive equation is most suitable, leading to the recommendation to perform indirect calorimetry when available. A more balanced nitrogen profile has been shown following a high-protein, hypocaloric feeding regimen as compared to a eucaloric one while also demonstrating better outcomes. Summary: Future studies should focus on finding a method to determine appropriate energy requirements and validate the benefits of a high-protein, hypocaloric feeding regimen in critically ill obese patients.

Circulating bioactive adrenomedullin as a marker of sepsis, septic shock and critical illness

BackgroundBiomarkers can be of help to understand critical illness and to identify and stratify sepsis. Adrenomedullin is a vasoactive hormone, with reported prognostic and potentially therapeutic value in sepsis. The primary aim of this study was to investigate the association of circulating bioactive adrenomedullin (bio-ADM) levels at intensive care unit (ICU) admission with mortality in sepsis patients and in a general ICU population. Secondary aims included the association of bio-ADM with organ failure and the ability of bio-ADM to identify sepsis.MethodsIn this retrospective observational study, adult patients admitted to one of four ICUs during 2016 had admission bio-ADM levels analysed. Age-adjusted odds ratios (OR) with 95% CI for log-2 transformed bio-ADM, and Youden’s index derived cut-offs were calculated. The primary outcome was 30-day mortality, and secondary outcomes included the need for organ support and the ability to identify sepsis.ResultsBio-ADM in 1867 consecutive patients were analysed; 632 patients fulfilled the sepsis-3 criteria of whom 267 had septic shock. The median bio-ADM in the entire ICU population was 40 pg/mL, 74 pg/mL in sepsis patients, 107 pg/mL in septic shock and 29 pg/mL in non-septic patients. The association of elevated bio-ADM and mortality in sepsis patients and the ICU population resulted in ORs of 1.23 (95% CI 1.07–1.41) and 1.22 (95% CI 1.12–1.32), respectively. The association with mortality remained after additional adjustment for lactate in sepsis patients. Elevated bio-ADM was associated with an increased need for dialysis with ORs of 2.28 (95% CI 2.01–2.59) and 1.97 (95% CI 1.64–2.36) for the ICU population and sepsis patients, respectively, and with increased need of vasopressors, OR 1.33 (95% CI 1.23–1.42) (95% CI 1.17–1.50) for both populations. Sepsis was identified with an OR of 1.78 (95% CI 1.64–1.94) for bio-ADM, after additional adjustment for severity of disease. A bio-ADM cut-off of 70 pg/mL differentiated between survivors and non-survivors in sepsis, but a Youden’s index derived threshold of 108 pg/mL performed better.ConclusionsAdmission bio-ADM is associated with 30-day mortality and organ failure in sepsis patients as well as in a general ICU population. Bio-ADM may be a morbidity-independent sepsis biomarker.

Ketamine vs. haloperidol for prevention of cognitive dysfunction and postoperative delirium: A phase IV multicentre randomised placebo-controlled double-blind clinical trial

Study objectiveDelirium is frequently observed in the postoperative and intensive care unit (ICU) population. Due to the multifactorial origin of delirium and according to international guidelines (e.g., American Geriatrics Society; Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) guideline), there are several but no incontestable options for prevention and symptomatic treatment.The purpose of the Baden PRIDe (Prevention and Reduction of Incidence of postoperative Delirium) trial was to determine whether postoperative cognitive dysfunction and delirium could be prevented by the combination of possible preventive agents such as haloperidol and ketamine. In addition, pre- and postoperative levels of the biomarkers cortisol, neuron specific enolase (NSE) and S100β were measured to investigate their dynamics in delirious and non-delirious patients after surgery. DesignThe Baden PRIDe Trial was an investigator-initiated, phase IV, two-centre, randomised, placebo-controlled, double-blind clinical trial. SettingPerioperative care. Patients182 adult patients that underwent elective or emergency surgery under general or combined (i.e., general and regional) anaesthesia. InterventionsPre-anaesthetic, pharmacologic prevention of postoperative brain dysfunction with haloperidol, ketamine, and the combination of both vs. placebo. MeasurementsAssessment of cognitive performance pre- and postoperatively with the MMSE, the DOS, the Nursing Delirium Screening Scale (Nu-DESC) or the Intensive Care Delirium Screening Checklist (ICDSC) during ICU stay. Main resultsNone of the three study arms – haloperidol, ketamine, or both drugs combined - was significantly superior to placebo for prevention of postoperative brain dysfunction and delirium (P = 0.39). Measured levels of postoperative cortisol were significantly higher in delirious patients. S-100β levels were significantly higher in all postoperative outcome groups (cognitive impairment, delirium, no cognitive decline), whereas postoperative NSE levels declined in all groups. ConclusionsThe study results offer no possibility for a novel recommendation for prevention of postoperative cognitive decline including delirium. Perioperative S-100β trajectories in patients with cognitive deterioration suggest affection of glial cells in particular. Trial registrationClinicalTrials.govNCT02433041; registered on April 7, 2015.

Incidence of Thrombotic Events and Outcomes in COVID-19 Patients Admitted to Intensive Care Units.

IntroductionWhile coronavirus disease 2019 (COVID-19) mostly causes respiratory illnesses, emerging evidence has shown that patients with severe COVID-19 can develop complications like venous thromboembolism (VTE) and arterial thrombosis as well. The incidence of thrombosis among critically ill patients in the literature has been highly variable, ranging from 25 to 69%. Similarly, reported mortality among critically ill patients has been highly variable too, and it has ranged from 30 to 97%. In this study, we analyzed data from a large database to address the incidence, the risk factors leading to thrombotic complications, and mortality rates among COVID-19 patients.Material and methodsData were obtained from TriNetX (TriNetX, Inc., Cambridge, MA), a multinational clinical research platform that collects medical records from 42 healthcare organizations (HCOs). All nominal data were compared using the chi-squared test. Alpha of <0.05 was considered statistically significant. We used Benjamini-Hochberg correction with a false discovery rate of 0.1 to correct for multiple comparisons.ResultsWe identified 18,652 COVID-19-positive patients, with a median age of 50.7 years [interquartile range (IQR): 31.8-69.6]; among them, 51.8% (9,672) were males and 48.2% (8,951) were females. Of these patients, 630 [3.37%; median age: 61 years (IQR: 44.9-77.1)] were critically ill, requiring intensive care unit (ICU) care within one month of their diagnosis. Men were over-represented among the ICU patients when compared to women (3.7% vs 3%, p=0.009, Χ2=6.66). African Americans were over-represented among the ICU patients when compared to Caucasians (8.5% vs 4%, p<0.0001, Χ2=76.65). Older patients, i.e., 65 years and older, were over-represented in the ICU compared to patients aged 18-64 years (6.8% vs 2.5%, p<0.0001, Χ2=121.43).The cumulative incidence of thrombotic events in the ICU population was 20.4% (129/630). Thrombotic events were significantly more common in patients who were 65 years and older when compared to patients in the age group of 18-64 years (24.6% vs 17.31%, p=0.02, Χ2=5.38). Mortality among ICU patients was higher in those who were 65 years and older when compared to the age group of 18-64 years (31.9% vs 17.3% p=0.0003, Χ2=18.41). The overall mortality in the study population was higher in patients who were 65 years and older when compared to patients aged 18-64 years (18.55% vs 1.4%, p<0.0001, Χ2=1915).ConclusionsAmong COVID-19 patients, men, African Americans, and people who are 65 years and older are more likely to have severe disease and require ICU level of care. Patients who are 65 years and older are more likely to have thrombotic events, myocardial infarction (MI), and stroke. Overall mortality and ICU mortality are higher among COVID-19 patients who are 65 years and older.

Systematic review of family engagement interventions in neonatal, paediatric, and adult ICUs.

The purpose of this systematic review was to evaluate interventions that have been used to engage families in direct care activities (active family engagement) in adult, paediatric, and neonatal intensive care unit (ICU) settings. Family engagement is universally advocated across ICU populations and practice settings; however, appraisal of the active family engagement intervention literature remains limited. Ovid Medline, PsycArticles & PsycInfo, Scopus, and CINAHL were searched for family interventions that involved direct care of the patient to enhance the psychological, physical, or emotional well-being of the patient or family in neonatal, paediatric, or adult ICUs. Studies were included if an active family engagement intervention was evaluated. Studies were excluded if they were not published in English or reported non-interventional research. A total of 6210 abstracts were screened and 19 studies were included. Most studies were of low to moderate quality and were conducted in neonatal ICUs within the United States. Intervention dosage and frequency varied widely across studies. The interventions focused on developmental care (neonatal ICU) and involved families in basic patient care. Family member outcomes measured included satisfaction, stress, family-centred care, confidence, anxiety, and depression. Most studies found improvements in one or more outcomes. There is a paucity of literature about active family engagement interventions, especially in adult and paediatric populations. The optimal dosage and frequency of family engagement interventions remains unknown. Our systematic review found that data are limited on the relationship between family engagement and patient outcomes, and provides a timely appraisal to guide future research. Further research on the efficacy of family engagement interventions is warranted. The translation of active family engagement interventions into clinical practice should also be supported.

Systematic review of diagnostic methods for acute respiratory distress syndrome.

RationaleAcute respiratory distress syndrome (ARDS) is currently diagnosed by the Berlin definition, which does not include a direct measure of pulmonary oedema, endothelial permeability or pulmonary inflammation. We hypothesised that biomarkers of these processes have good diagnostic accuracy for ARDS.MethodsMedline and Scopus were searched for original diagnostic studies using minimally invasive testing. Primary outcome was the diagnostic accuracy per test and was categorised by control group. The methodological quality was assessed with QUADAS-2 tool. Biomarkers that had an area under the receiver operating characteristic curve (AUROCC) of >0.75 and were studied with minimal bias against an unselected control group were considered to be promising.ResultsForty-four articles were included. The median AUROCC for all evaluated tests was 0.80 (25th to 75th percentile: 0.72–0.88). The type of control group influenced the diagnostic accuracy (p=0.0095). Higher risk of bias was associated with higher diagnostic accuracy (AUROCC 0.75 for low-bias, 0.77 for intermediate-bias and 0.84 for high-bias studies; p=0.0023). Club cell protein 16 and soluble receptor for advanced glycation end-products in plasma and two panels with biomarkers of oxidative stress in breath showed good diagnostic accuracy in low-bias studies that compared ARDS patients to an unselected intensive care unit (ICU) population.ConclusionThis systematic review revealed only four diagnostic tests fulfilling stringent criteria for a promising biomarker in a low-bias setting. For implementation into the clinical setting, prospective studies in a general unselected ICU population with good methodological quality are needed.

Association of Secondary Diagnosis of HF with 90-day Mortality in Acutely Ill Patients

Introduction Heart failure (HF) is a common concomitant diagnosis in the intensive care unit (ICU) population. Whether mortality is impacted by secondary diagnosis of HF is less well studied. We sought to assess the impact of secondary diagnosis of heart failure on 90-day mortality. Hypothesis A secondary diagnosis of HF is associated with increased mortality in acutely ill patients. Methods This was a retrospective study using the de-identified Medical Information Mart for Intensive Care III (MIMIC-III) database. We identified patients admitted between 2001 and 2012 to adult ICUs with secondary diagnosis HF which we defined as HF that coexisted before admission or developed during admission. Patients admitted for primary HF were excluded. We compared baseline characteristics of the two groups using parametric and non-parametric tests for continuous variables and Chi-Squares test for dichotomous variables. Multivariate logistic regression was used to examine the association of secondary diagnosis HF with 90-day mortality. Our analysis adjusted for age, sex, race, disease severity (simplified acute physiology scores [SAPS II]), length of stay (LOS), diuretics, average sodium, blood sugar levels and multiple co-morbidities. Results Among 34,540 admissions, there were 7,581 (22%) patients with a secondary diagnosis HF. Compared to Patients with HF, patients without HF were older (mean age 73 vs 62 years); had a higher mean length of ICU stay (4.95 days vs 3.75 days). Secondary diagnosis of HF was independently associated with increased risk of 90-day mortality (Table 1). Conclusion In this ICU population, a secondary HF diagnosis was significantly associated with higher 90-day mortality.

Spanish version of the Perme Intensive Care Unit Mobility Score: Minimal detectable change and responsiveness.

The purpose of this study was to determine the minimal detectable change (MDC) and responsiveness of the Perme Score when used in the adult intensive care unit (ICU) population. This is a prospective longitudinal study which was conducted from November 2016 to July 2017 in Cali, Colombia. Four physical therapists with observer and evaluator roles, applied the Perme Score upon ICU admission and discharge. The Consensus-based Standards for the Selection of Health Measurement Instruments Protocol standards to analyze sensitivity to change were used. The sample size was defined considering the lowest concordance proportion reported (68.6%), and a Kappa Index of 0.2784 or higher to guarantee an adequate n, and a 95% reliability level. One hundred and forty-two patients were enrolled in the study. There were 51.4% men with an average age of 58 ± 17 years. Invasive mechanical ventilation was employed in 42.0% of the patients. The MDC for the Perme Score was 1.36, and 80% of patients demonstrated higher or equal values, detecting a significant difference in the type of weaning and the length of stay in the ICU (p < 0.005). The Perme Score has an MDC of 1.36 points and shows evidence of being sensitive to change. Therefore, the findings validate the responsiveness of the instrument.

Bundled care in acute kidney injury in critically ill patients, a before-after educational intervention study

BackgroundAcute kidney injury (AKI) often occurs in critically ill patients. AKI is associated with mortality and morbidity. Interventions focusing on the reduction of AKI are suggested by the Kidney Disease: Improving Global Outcomes guideline. We hypothesized that these educational interventions would improve outcome in patients admitted to the Intensive Care Unit (ICU).MethodsThis was a pragmatic single-centre prospective observational before-after study design in an ICU in a tertiary referral hospital. All consecutive patients admitted to the ICU irrespective their illness were included. A ‘Save the Kidney’ (STK) bundle was encouraged via an educational intervention targeting health care providers. The educational STK bundle consisted of optimizing the fluid balance (based on urine output, serum lactate levels and/or central venous oxygen saturation), discontinuation of diuretics, maintaining a mean arterial pressure of at least 65 mmHg with the potential use of vasopressors and critical evaluation of the indication and dose of nephrotoxic drugs. The primary outcome was the composite of mortality, renal replacement therapy (RRT), and progression of AKI. Secondary outcomes were the components of the composite outcome the severity of AKI, ICU length of stay and in-hospital mortality.Main resultsThe primary outcome occurred in 451 patients (33%) in the STK group versus 375 patients (29%) in the usual care group, relative risk (RR) 1.16, 95% confidence interval (CI) 1.03–1.3, p < 0.001. Secondary outcomes were, ICU mortality in 6.8% versus 5.6%, (RR 1.22, 95% CI 0.90–1.64, p = 0.068), RRT in 1.6% versus 3.6% (RR 0.46, 95% CI 0.28–0.76, p = 0.002), and AKI progression in 28% versus 24% (RR 1.18, 95% CI 1.04–1.35, p = 0.001).ConclusionsProviding education to uniformly apply an AKI care bundle, without measurement of the implementation in a non-selected ICU population, targeted at prevention of AKI progression was not beneficial.

Surgical Support for Severe COVID-19 Patients: A Retrospective Cohort Study in a French High-Density COVID-19 Cluster.

Background. The COVID-19 epidemic has resulted in a massive surge in the need for intensive care unit (ICU) care. To avoid being overwhelmed, hospitals had to adapt and support the ICU teams in structured ICU care including involving surgical teams. This work aims at describing the collaborative efforts between the ICU care team and the Surgical Task Force (STF) during a surge of ICU activity in a University Hospital in a French high-density COVID-19 cluster. Study Design. This retrospective single center study analyzed the STF workflow and the ICU population. The study included 55 patients hospitalized in our ICU, ICU-converted step-down units, and post-anesthesia care units. The primary measure was the global daily STF activity. The secondary measure was the daily activity for each of the 5 tasks accomplished by the STF. Results. The STF attempted 415 phone calls for 55 patients’ families, 237 mobilizations of patients requiring prone positions, follow-up of 20 patients requiring medevac, and contribution to ethical discussion for 2 patients. The mean (SD) daily number of successful phones calls, ethical discussions, mobilizations of patients requiring prone positions and medevac follow-up were 18 (7), .1 (.4), 10 (7), and 2 (3), respectively. No actions for discharge summaries writing were required. The maximum number of daily mobilizations for patients requiring prone positions was 25. The maximum number of daily attempted phone calls and successful phone calls were 37 and 26, respectively. Conclusion. Surgeons’ technical and nontechnical skills represented an effective support for ICU teams during the COVID-19 pandemic.

Elderly patients with cancer admitted to intensive care unit: A multicenter study in a middle-income country.

Very elderly critically ill patients (ie, those older than 75 or 80 years) are an increasing population in intensive care units. However, patients with cancer have encompassed only a minority in epidemiological studies of very old critically-ill patients. We aimed to describe clinical characteristics and identify factors associated with hospital mortality in a cohort of patients aged 80 or older with cancer admitted to intensive care units (ICUs). This was a retrospective cohort study in 94 ICUs in Brazil. We included patients aged 80 years or older with active cancer who had an unplanned admission. We performed a mixed effect logistic regression model to identify variables independently associated with hospital mortality. Of 4604 included patients, 1807 (39.2%) died in hospital. Solid metastatic (OR = 2.46; CI 95%, 2.01-3.00), hematological cancer (OR = 2.32; CI 95%, 1.75-3.09), moderate/severe performance status impairment (OR = 1.59; CI 95%, 1.33-1.90) and use of vasopressors (OR = 4.74; CI 95%, 3.88-5.79), mechanical ventilation (OR = 1.54; CI 95%, 1.25-1.89) and renal replacement (OR = 1.81; CI 95%, 1.29-2.55) therapy were independently associated with increased hospital mortality. Emergency surgical admissions were associated with lower mortality compared to medical admissions (OR = 0.71; CI 95%, 0.52-0.96). Hospital mortality rate in very elderly critically ill patients with cancer with unplanned ICU admissions are lower than expected a priori. Cancer characteristics, performance status impairment and acute organ dysfunctions are associated with increased mortality.

Development of a Frailty Index from Routine Hospital Data in Perioperative and Critical Care.

Frailty is common in surgical and intensive care unit (ICU) populations, yet it is not routinely measured. Frailty indices are able to quantify this condition across a range of health deficits. We aimed to develop a frailty index (FI) from routinely collected hospital data in a surgical and ICU population. Prospective observational single-center cohort study. Tertiary referral metropolitan Australian hospital. A total of 336 individuals aged 65 and older undergoing surgery or aged 50 and older admitted to the ICU. Routine admission health data were used to derive an FI comprising 36 health deficits. We examined the FI correlation with existing frailty tools (Clinical Frailty Scale [CFS] and Edmonton Frail Scale [EFS]) and assessed its predictive ability for negative outcomes including 30-day mortality. Median FI was .17 (interquartile range [IQR]) = .10-.24) for ICU patients and .17 (IQR = .11-.25) for surgical patients; maximum FI was .58, and 25% (95% confidence interval [CI] = 10.4-29.6) of patients overall were diagnosed with frailty (FI score ≥.25). Correlation was strong between the FI and the EFS: ρ = .76 (95% CI = .70-.83) for ICU patients and .71 (95% CI = .64-.78) for surgical patients, and the CFS was .77 (95% CI = .70-.84) for ICU patients and .72 (95% CI = .65-.79) for surgical patients. The FI had good discriminative ability for prediction of 30-day mortality in ICU patients (multivariate odds ratio for each increase in FI of .1 = 2.04 [95% CI = 1.19-3.48]), comparable with the performance of the Acute Physiology and Chronic Health Evaluation III score (ICU patients) and the Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity score (surgical patients). It is feasible to construct an FI from hospital admission data in a cohort of critically ill and surgical patients.

Unplanned postdischarge healthcare utilisation, discharge readiness, and perceived quality of teaching in mothers of neonates hospitalized in a neonatal intensive care unit: A descriptive and correlational study

BackgroundDischarge teaching has been positively associated with discharge readiness in various care settings and patient types. Association of discharge readiness with unplanned use of health services has not received as much attention in the neonatal intensive care unit (NICU) population, but has been negatively associated in parents of older children. ObjectivesThe objective of the study was to describe and assess relationships between maternal readiness for neonates' discharge, discharge teaching, and unplanned use of health services after discharge from an NICU. MethodsMothers from an NICU of a tertiary referral hospital in Switzerland completed the “Readiness for Hospital Discharge Scale” and the “Quality of Discharge Teaching Scale parental forms” in the 24 h preceding discharge. Telephone interviews evaluating the unplanned use of health services were conducted 28 days after discharge. Simple linear regressions and multiple regressions were used to explore the links between the readiness, perceived quality of discharge, and unplanned use of health services. ResultsOf the 71 participants, 75% (n = 53%) felt ready for discharge when asked directly, and for 60% (n = 42) of them, the amount of discharge teaching received was equal to or higher than that needed, but with high heterogeneity in scores. For 38% of mothers (n = 27), the expected support from the medical care of their child after discharge was deemed insufficient. In the month after discharge, unplanned use of health services occurred in 46% of the participants (n = 32). Perceived quality of teaching positively predicted readiness for discharge (R2 = 0.24, p = 0.0004). Unplanned use of health services correlated neither with readiness nor with perceived teaching quality. ConclusionsAt discharge, mothers felt mostly ready and well prepared to go home. In the month after discharge, almost half used health services in an unplanned manner. Further exploration of reasons leading to this high rate of postdischarge healthcare utilisation is warranted.

EARLY PROBIOTICS IN PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA AFTER MULTIPLE TRAUMA

Objective: Using probiotics in preventing ventilator-associated pneumonia (VAP) remain controversial due to different intensive care unit (ICU) populations included in such studies. The aim of this study is to evaluate the role of probiotics in prophylaxis of VAP after multiple trauma.&#x0D; Methods: Sixty-five adult multiple trauma patients on mechanical ventilator (expected ≥48 h) after admission to the Critical Care Medicine Department, Alexandria Main University Hospital from June to November 2018. Patients were randomly assigned using computer sheet into two groups; probiotics group (32 patients received one Lacteol Forte® sachet through orogastric/nasogastric tube 3 times daily during their ICU stay) and control group (33 patients received similar regimen of placebo sachets). All patients were followed up and subjected to all possible strategies of the diagnosis of microbiologically confirmed VAP.&#x0D; Results: Sixty-five patients were enrolled with a mean of age (39.48±7.692) years, 80% of them were male. Regarding the incidence of VAP, it was 18.46% of all patients without statistically significant difference between probiotics group (15.63%) and control group (21.21%) (p=0.751).&#x0D; Conclusion: Routine use of early probiotics in mechanically ventilated multiple trauma patients was not associated with lower incidence of VAP, duration of MV, or ICU mortality.

Results from the first audit of an intensive care unit in Botswana.

Botswana is an economically stable middle-income country with a developing health system and a large HIV and infectious disease burden. Princess Marina Hospital (PMH) is the largest referral and teaching hospital with a mixed eight-bed intensive care unit (ICU). To conduct an audit of PMH ICU in order to investigate major admission categories and quantify morbidity and mortality figures using a validated scoring system for quality improvement, education and planning purposes. PMH medical records and laboratory data were accessed to record demographics, referral patterns, diagnoses, HIV status, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores and mortality rates. A total of 182 patients >14 years of age were enrolled over a 12-month period from April 2017 - March 2018. Patient's mean age was 42.9 years, males represented 56.6% of the study population and surgical conditions accounted for 46% of diagnostic categories. Sixty percent of the patients were HIV-negative and 12% had no HIV status recorded. The mean APACHE II score was 25 and the mean length of stay in ICU was 10.3 days. Higher APACHE II scores were associated with higher mortality regardless of HIV status. The overall mortality was 42.8% and there was no difference in mortality rates in ICU or at 30 days between HIV-positive and HIV-negative ICU patient groups. The PMH ICU population is young with a high mean APACHE II score, significant surgical and HIV burdens and a high mortality rate. PMH ICU has significant logistical challenges making comparison with international ICUs challenging, and further research is warranted. This study is the first published audit for an intensive care unit in Botswana. The findings are especially relevant for the development of critical care capacity in the country during the current COVID-19 pandemic. We advocate for the establishment of an ICU registry in the country to allow ongoing accurate research in the field of critical care medicine and to improve healthcare for all critically ill patients in Botswana.

Validation of Cardiac Surgery Score (CASUS) in Postoperative Cardiac Patients.

Introduction. Cardiac Surgery Score (CASUS) was introduced in 2005 as the first postoperative scoring system specific for patients who had cardiac surgery. Prior to this, European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been used preoperatively, while Intensive Care National Audit and Research Centre Score (ICNARC) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, which are widely used in general intensive care unit population, have been used to score cardiac patients postoperatively. The development of CASUS by Hekmat and colleagues for use in postoperative cardiac patients aims to change this. We wanted to validate CASUS against the well-established preoperative Logistic EuroSCORE, and postoperative APACHE II and ICNARC scores. Method. Institutional approval for this study was granted by the Audit and Clinical Governance Committee. We analyzed prospectively collected data of patients who had cardiac surgery in Castle Hill Hospital between January 2016 and September 2018. All patients who underwent surgery in the unit would have had Logistic EuroSCORE, APACHE, and ICNARC scores calculated as standard. CASUS was then calculated for these patients based on their day 1 postoperative variables. The scoring systems were compared and data presented as area under the receiver operating characteristic curve. Result. Our study shows that CASUS is the best predictor of mortality followed by ICNARC, Logistic EuroSCORE, and APACHE II. ICNARC score remains the most accurate predictor of renal and pulmonary complication followed by CASUS. Conclusion. CASUS is a useful scoring system in post-cardiac surgery patients. The accuracy of CASUS and ICNARC scores in predicting mortality, pulmonary, and renal complications are comparable.

The ISTH DIC score predicts outcome in non-septic patients admitted to a cardiovascular intensive care unit

BackgroundThe International Society of Thrombosis and Haemostasis (ISTH) disseminated intravascular coagulation (DIC) score is widely used to predict mortality in critically ill - typically septic - patients. The objective of this study was to investigate whether the ISTH DIC-2001 and DIC-2018 score can be used to predict the 30-day mortality in non-septic patients in an intensive care unit (ICU). MethodsIn this single-center, prospective observational study we included all patients ≥18 years of age who were admitted to a medical ICU with a focus on cardiovascular diseases between August 2012 and 2013. The DIC-2001 and DIC-2018 scores were calculated on admission (DIC-2001-0h and DIC-2018-0h) and 72 hours thereafter (DIC-2001-72h and DIC-2018-72h) and were classified as overt when ≥ 5 for DIC-2001 and ≥ 4 for DIC-2018. ResultsA total of 233 patients were included in this study. Excluding septic patients and patients after routine surgery/procedures, we calculated the DIC score for 167 patients (32.4% female; median age 64.9 years). Overt DIC-2001-0h, DIC-2018-0h and overt DIC-2001-72h scores were associated with a significantly higher 30-day mortality rate (52.9% vs. 25.0%, 46.2% vs 21.2%, and 57.1% vs. 23.7%; p < 0.04). The DIC-2001 scores and the DIC-2018-0h score significantly predicted the 30-day mortality. ConclusionThis study suggests that the DIC score may be applied to non-septic ICU populations, and indicates that it is a useful tool for mortality prediction, regardless of the underlying disease.

Baseline Characteristics and Outcomes Among Patients with Complicated Skin and Soft Tissue Infections Admitted to the Intensive Care Unit: Analysis of the Phase 3 COVERS Randomized Trial of Ceftaroline Fosamil Versus Vancomycin Plus Aztreonam.

AimExploratory analyses evaluated patient characteristics and outcomes among patients with complicated skin and soft tissue infection (cSSTI) in the phase 3 COVERS study who were admitted to an intensive care unit (ICU).MethodsAdults with cSSTI (surface area ≥ 75 cm2) and evidence of systemic inflammation and/or underlying comorbidities were randomized 2:1 to intravenous ceftaroline fosamil (600 mg every 8 h [q8h]) or vancomycin (15 mg/kg every 12 h) plus aztreonam (1 g q8h) for 5–14 days. Clinical response and ICU length of stay (LOS) within first hospitalization were evaluated in the modified intent-to-treat (MITT) and clinically evaluable (CE) populations; a Cox proportional hazards model identified factors associated with increased hospital LOS.ResultsOverall, 42 of 761 randomized patients were admitted to the ICU (ceftaroline fosamil, n = 32; vancomycin plus aztreonam, n = 10) prior to, or at start of, study treatment. Baseline differences between the ICU and non-ICU populations were indicative of more severe disease in ICU patients; within this subset, there were also some notable imbalances between treatment groups. Clinical cure rates at test-of-cure (ceftaroline fosamil vs. vancomycin plus aztreonam) were generally similar in the non-ICU and ICU subsets (MITT population 79% vs. 79% and 69% vs. 90.0%, respectively; CE population 87% vs. 85% and 80% vs. 89%, respectively). Median ICU LOS was 8 vs. 13 days, respectively. ICU admission was a risk factor predicting increased hospital LOS (P < 0.001).ConclusionsClinical outcomes for patients admitted to the ICU were generally similar to non-ICU patients, despite more severe baseline disease, with shorter median treatment duration in the ceftaroline fosamil group. ICU admission was associated with longer hospital LOS. Given the small sample size and unbalanced patient and disease characteristics within the ICU subgroup, differences between treatment groups should be interpreted with caution.Trial registrationClinicalTrials.gov identifier, NCT01499277.Electronic supplementary materialThe online version of this article (10.1007/s40121-020-00297-3) contains supplementary material, which is available to authorized users.

Muscle Mass Loss in the Older Critically Ill Population: Potential Therapeutic Strategies.

Skeletal muscle plays a critical role in everyday life, and its age-associated reduction has severe health consequences. The pre-existing presence of sarcopenia, combined with anabolic resistance, protein undernutrition, and the pro-catabolic/anti-anabolic milieu induced by aging and exacerbated in critical care, may accelerate the rate at which skeletal muscle is lost in patients with critical illness. Advancements in intensive care unit (ICU)-care provision have drastically improved survival rates; therefore, attention can be redirected toward other significant issues affecting ICU patients (e.g., length of stay, days on ventilation, nosocomial disease development, etc.). Thus, strategies targeting muscle mass and function losses within an ICU setting are essential to improve patient-related outcomes. Notably, loading exercise and protein provision are the most compelling. Many older ICU patients seldom meet the recommended protein intake, and loading exercise is difficult to conduct in the ICU. Nevertheless, the incorporation of physical therapy (PT), neuromuscular electrical stimulation, and early mobilization strategies may be beneficial. Furthermore, a number of nutrition practices within the ICU have been shown to improve patient-related outcomes ((e.g., feeding strategy [i.e., oral, early enteral, or parenteral]), be hypocaloric (∼70%-80% energy requirements), and increase protein provision (∼1.2-2.5 g/kg/d)). The aim of this brief review is to discuss the dysregulation of muscle mass maintenance in an older ICU population and highlight the potential benefits of strategic nutrition practice, specifically protein, and PT within the ICU. Finally, we provide some general guidelines that may serve to counteract muscle mass loss in patients with critical illness.