Intensive Care Unit Population Research Articles

Clinical profile of patients with systemic autoimmune diseases treated in the intensive care unit who developed diffuse alveolar haemorrhage - an observational retrospective cohort study.

Patients with autoimmune diseases constitute arelatively low percentage of the intensive care unit (ICU) population but their prognosis is particularly poor, partially due to involvement of multiple organs as well as complications related to immunosuppressive treatment. Diffuse alveolar haemorrhage (DAH) is one of the most life-threatening presentations of autoimmune diseases, associated with worse outcomes. The aim of this study is to report about clinical factors associated with DAH in the ICU setting and to assess the survival in 5-year follow-up. This is an observational, retrospective, cohort study performed in the ICU of the University Hospital in Krakow, Poland. We enrolled 21 patients treated for the first time in the ICU due to autoimmune diseases, who developed DAH. Severity of patients' clinical condition was assessed on the first day using APACHE II, APACHE III, SAPS II and SOFA scores. Mortality was assessed during the ICU stay and in 5-year follow-up. The median age of the study population was 53 (18-78) years and 13 (61.9%) of patients were females. The most common diagnoses were granulomatosis with polyangiitis (38.1%), systemic lupus erythematosus (23.8%) and microscopic polyangiitis (14.3%). Most of the patients required mechanical ventilation (85.7%), renal replacement therapy (57.1%) and blood product transfusions (71.4%). Mortality in the ICU was 52.4%, while in both 1-year and 5-year follow-up it was 76.2%. Patients who develop DAH in the course of autoimmune diseases and are treated in the ICU have apoor prognosis and often require advanced therapeutic measures.

Improving Recognition and Reporting of Adverse Drug Reactions in the NICU: A Quality Improvement Project.

Introduction:Adverse drug reactions (ADRs) are under-recognized and under-reported in the Neonatal Intensive Care Unit (NICU) population, with up to 95% of all ADRs not reported. Compared with non-elderly adults, pediatric patients are 3 times more likely to experience an ADR, with varying rates from 0.6% to 16.8%. The Children’s Mercy NICU has an ADR rate of 0.29% (2015). This high rate presents an opportunity to increase recognition and reporting, and improve characterization of ADRs in the NICU.Methods:The primary aim of this quality improvement project was for 70% of patients who received specified medications (indomethacin, dexmedetomidine, fentanyl, lorazepam, dexamethasone, or hydrocortisone) in the first 3 months of age to be assessed daily for ADRs. We selected these medications due to the frequency of use and well-understood ADR associations. For each ADR recognized, the Naranjo score, was calculated and compared with the neonatal-specific Du score to assess the effectiveness of ADR characterization.Results:Implementation occurred on May 15, 2017. We completed 3 PDSA cycles over 1 year. The bedside monitoring tool was utilized 83% of the time. Twenty-eight potential ADRs were identified, far exceeding the number reported before implementation. The Du score appeared to better characterize ADRs compared with the Naranjo score.Conclusions:Use of a bedside monitoring tool improves ADR detection. We experienced challenges with consistently identifying patients on target drugs and getting the tool to the bedside. Application of the Du score for ADR classification in neonates appears to be more appropriate than the use of the Naranjo.

Should we admit more patients not requiring invasive ventilation to reduce excess mortality in Polish intensive care units? Data from the Silesian ICU Registry.

IntroductionMortality in Polish intensive care units (ICU) is excessively high. Only a few patients do not require intubation and invasive ventilation throughout the whole ICU treatment period. We aimed to define this population, as pre-emptive admissions of such patients may increase the population which benefits from ICU admission and reduce excessive mortality in Polish ICUs.Material and methodsData on 20 651 patients from the Silesian Registry of Intensive Care Units were analysed. Patients who did not require intubation and invasive ventilation (referred to as non-ventilated patients) were identified and compared to the remaining ICU population. Independent variables that influence being non-intubated in the ICU were identified.ResultsAmong 20 368 analyzed adult patients, only 1233 (6.1%) were in the non-ventilated group. Non-ventilated patients were younger, with fewer comorbidities and a lower APACHE II score at admission (13.0 ±7.1 vs. 23.7 ±8.6 points, p < 0.001). Patients with cardiac arrest prior to admission were particularly rare in this group (2.6% vs. 26.8%, p < 0.001). The ICU mortality among non-ventilated patients was 6 to 7 times lower (7.0% vs. 46.7%, p < 0.001). Independent variables that influenced the ICU stay in non-ventilated patients were: obstetric complications as the primary cause of ICU admission, presence of a systemic autoimmune disease, invasive monitoring as the primary cause of ICU admission, ICU readmission and the presence of cancer.ConclusionsNon-ventilated patients have a high potential for a favourable outcome. Pre‑emptive ICU admissions have a potential to reduce mortality in Polish ICUs.

Admission Hyperoxia Is a Risk Factor for Mortality in Pediatric Intensive Care: Numba A, Aneja H, Awad J, et al. Ped Crit Care Med. 2018;19(8):699-704

Hyperoxia has been associated with an increase in mortality in critically ill adult patients suffering from stroke, trauma, traumatic brain injury, and cardiac arrest. Hyperoxia has also been associated with increased mortality in adult intensive care unit (ICU) populations. This study was the first analysis of mortality and hyperoxia in mixed pediatric ICU (PICU) patients.

Addressing the inadvertent sodium and chloride burden in critically ill patients: a prospective before-and-after study in a tertiary mixed intensive care unit population

Addressing the inadvertent sodium and chloride burden in critically ill patients: a prospective before-and-after study in a tertiary mixed intensive care unit population

Is routine extubation overnight safe in cardiac surgery patients?

ObjectivesExpedient extubation after cardiac surgery has been associated with improved outcomes, leading to postoperative extubation frequently during overnight hours. However, recent evidence in a mixed medical-surgical intensive care unit population demonstrated worse outcomes with overnight extubation. This study investigated the impact of overnight extubation in a statewide, multicenter Society of Thoracic Surgeons database. MethodsRecords from 39,812 patients undergoing coronary artery bypass grafting or valve operations (2008-2016) and extubated within 24 hours were stratified according to extubation time between 06:00 and 18:00 (day) or between 18:00 and 6:00 (overnight). Outcomes including reintubation, mortality, and composite morbidity-mortality were evaluated using hierarchical regression models adjusted for Society of Thoracic Surgeons predictive risk scores. To further analyze extubation during the night, a subanalysis stratified patients into 3 groups: 06:00 to 18:00, 18:00 to 24:00, and 24:00 to 06:00. ResultsA total of 20,758 patients were extubated overnight (52.1%) and were slightly older (median age 66 vs 65 years, P < .001) with a longer duration of ventilation (4 vs 7 hours, P < .001). Day and overnight extubation were associated with equivalent operative mortality (1.7% vs 1.7%, P = .880), reintubation (3.7% vs 3.4%, P = .141), and composite morbidity-mortality (8.2% vs 8.0%, P = .314). After risk adjustment, overnight extubation was not associated with any difference in reintubation, mortality, or composite morbidity-mortality. On subanalysis, those extubated between 24:00 and 06:00 exhibited increased composite morbidity-mortality (odds ratio, 1.18; P = .001) but no difference in reintubation or mortality. ConclusionsExtubation overnight was not associated with increased mortality or reintubation. These results suggest that in the appropriate clinical setting, it is safe to routinely extubate cardiac surgery patients overnight.

Accuracy and reliability of bedside thoracic ultrasound in detecting pulmonary pathology in a heterogeneous pediatric intensive care unit population.

This study was designed to access sensitivity and specificity of detection of lung abnormalities by the ultrasound (US) done by PICU providers of varying levels of experience compared to CXR and to assess the inter-rater reliability in the interpretation of the USG findings. Up to three US examinations were performed on patients meeting eligibility criteria. US examinations were reported by the operator and remotely by an expert reader. Both operator and readers interpretation were correlated with CXR read by an independent pulmonologist. One hundred and thirty-five US examinations were performed on 91 patients over 9 months. Overall agreement between the operator and reader of the US was 0.53 (0.38-0.68). The agreement was highest with an expert-expert pair (0.75) and lowest with a novice-expert pair (0.27). Sensitivity and specificity of thoracic US to detect pulmonary abnormalities showed a high sensitivity by the operator (82.5%) compared to the reader (63.4%). Specificity was 25% and 42.8%, respectively. US was overall highly sensitive to detect pneumonia (96.4%) with a 100% PPV, but only modest for bronchiolitis. Lungs US is a rapid and sensitive bedside tool to assess lung consolidation in children in ICU. It, however, has low negative predictive values, and negative US examinations cannot rule out lung pathology.

Bleeding and thrombosis in intensive care patients with thrombocytopenia-Protocol for a topical systematic review.

Thrombocytopenia is a common condition in critically ill patients in the intensive care unit (ICU). It is associated with prolonged stay in the ICU, increased transfusion requirements, risk of bleeding and mortality. The evidence regarding the use of prophylactic platelet transfusion and thrombosis prophylaxis in patients with thrombocytopenia in the ICU is unknown. To direct future research, we aim to assess the current evidence regarding prophylactic platelet transfusion and thrombosis prophylaxis on patient-important benefits and harms in the ICU population. We will conduct a topical systematic review of all study designs (ie no study design will per se be excluded from the proposed review) in accordance with the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) statements. We will include studies on adult patients in the ICU where the incidence of thrombocytopenia and the predefined outcome measures, including mortality, quality-of-life, thrombotic events and haemorrhagic events are reported. We will provide descriptive analyses of the included studies/trials, ie no meta-analyses will be conducted, and the quality of evidence will be assessed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The outlined topical systematic review will provide important data on the benefits and harms of prophylactic platelet transfusion and thrombosis prophylaxis in ICU patients with thrombocytopenia and provide estimates on the rate of thrombocytopenia in this vulnerable population.

Management and weaning from mechanical ventilation in neurologic patients.

In the early phase following severe brain injury (BI), mechanical ventilation (MV) is often needed to prevent airway from aspiration, control PaCO2 and PaO2 and avoid secondary brain insults. Although patients with BI are frequently hospitalized in the intensive care unit (ICU) without respiratory problems, they display longer durations of MV and a challenging weaning process compared to other ICU populations. Historically, the MV settings of BI patients associated high tidal volume with low or no positive end-expiratory pressure (PEEP), for neurological reasons. The extensive data about the beneficial effects of protective ventilation in patients without acute respiratory distress syndrome, have questioned the consequences of such management in BI patients. Recent studies suggest that protective ventilation is safe and could even bear significant impact on morbidity in these patients. The MV weaning process is also challenging, since these patients display a high rate of extubation failure. Recently, new clinical scales of successful extubation have been highlighted combining airway and neurologic operators. A minimal level of arousal should be achieved before extubation, but the Glasgow Coma Score has been inconsistently associated with successful extubation, probably owing to the challenging quantification in intubated patients. Early tracheostomy seems to bear positive effects on morbidity in BI patients. Nonetheless the level of evidence remains poor and no strong recommendations can be made on this topic. Overall, the respiratory bundle of care in BI patients could be readapted with the new data available in the literature. Even if they bear positive impact on morbidity in ICU, their consequences on neurological recovery have yet to be adequately assessed.

Acute Respiratory Failure and Pulmonary Complications in End-Stage Liver Disease.

Acute respiratory failure has a high mortality in patients with end-stage liver disease (ESLD). These patients may develop acute respiratory failure for reasons specific to advanced liver disease, including hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax. They may also develop respiratory complications due to conditions seen in the general intensive care unit population to which ESLD patients are at higher risk, including infection, volume overload, and the acute respiratory distress syndrome. Management of these patients is complicated and multifaceted, and a comprehensive understanding of the etiologies and treatment of acute respiratory failure is critical in this high-risk patient population. This article reviews current evidence surrounding the prevalence, management, and complications of the various etiologies of acute respiratory failure in ESLD patients.

Risk factors for new-onset atrial fibrillation on the general adult ICU: protocol for a systematic review

IntroductionAtrial fibrillation (AF) is a common arrhythmia in the critical care environment. New-onset AF is associated with increased mortality and intensive care unit (ICU) length of stay. Observational studies have...

Probiotic and synbiotic therapy in the critically ill: State of the art.

Recent medical history has largely viewed our bacterial symbionts as pathogens to be eradicated rather than as essential partners in optimal health. However, one of the most exciting scientific advances in recent years has been the realization that commensal microorganisms (our microbiome) play vital roles in human physiology in nutrition, vitamin synthesis, drug metabolism, protection against infection, and recovery from illness. Recent data show that loss of "health-promoting" microbes and overgrowth of pathogenic bacteria (dysbiosis) in patients in the intensive care unit (ICU) appears to contribute to nosocomial infections, sepsis, and poor outcomes. Dysbiosis results from many factors, including ubiquitous antibiotic use and altered nutrition delivery in illness. Despite modern antibiotic therapy, infections and mortality from often multidrug-resistant organisms are increasing. This raises the question of whether restoration of a healthy microbiome via probiotics or synbiotics (probiotic and prebiotic combinations) to intervene on ubiquitous ICU dysbiosis would be an optimal intervention in critical illness to prevent infection and to improve recovery. This review will discuss recent innovative experimental data illuminating mechanistic pathways by which probiotics and synbiotics may provide clinical benefit. Furthermore, a review of recent clinical data demonstrating that probiotics and synbiotics can reduce complications in ICU and other populations will be undertaken. Overall, growing data for probiotic and symbiotic therapy reveal a need for definitive clinical trials of these therapies, as recently performed in healthy neonates. Future studies should target administration of probiotics and synbiotics with known mechanistic benefits to improve patient outcomes. Optimally, future probiotic and symbiotic studies will be conducted using microbiome signatures to characterize actual ICU dysbiosis and determine, and perhaps even personalize, ideal probiotic and symbiotic therapies.

Video capsule endoscopy as a tool for evaluation of obscure overt gastrointestinal bleeding in the intensive care unit.

Background and study aims Video capsule endoscopy (VCE) is a minimally invasive tool that helps visualize the gastrointestinal tract from the esophagus to the right colon without the need for sedation or preparation. VCE is safe with very few contraindications. However, its role and safety profile in the intensive care unit (ICU) population have not been reported. The aim of this study is to evaluate the safety, efficacy, and feasibility of VCE use in ICU patients. Patients and methods We conducted a single-center retrospective observational study of patients who underwent VCE for evaluation of obscure overt gastrointestinal bleeding in the ICU between 2008 and 2016. Results This study included 48 patients who were admitted to the UMass Memorial Medical Center ICUs for gastrointestinal bleeding. VCE was successfully completed in 43/48 (90 %) patients. The entire length of small bowel could be evaluated in 75 % and the source of bleeding was identified in 44 % of the patients. The most commonly identified source of bleeding included small bowel angioectasias, duodenal erosions/ulcers, and small bowel polyps. No major complications could be attributed to the VCE. Only 1 capsule was retained after 2 wk; however, there was no incidence of bowel obstruction, perforation, or capsule aspiration. Conclusions This observational retrospective study demonstrates that VCE may be a safe, feasible, and effective diagnostic tool in evaluation of gastrointestinal bleeding in the ICU population with few complications. VCE may be a safe diagnostic prelude and be a guide to the correct therapeutic procedure if needed, in the context of patients who are seriously ill.

The age of blood in pediatric intensive care units (ABC PICU): study protocol for a randomized controlled trial

BackgroundThe “Age of Blood in Children in Pediatric Intensive Care Unit” (ABC PICU) study is a randomized controlled trial (RCT) that aims to determine if red blood cell (RBC) unit storage age affects outcomes in critically ill children. While RBCs can be stored for up to 42 days in additive solutions, their efficacy and safety after long-term storage have been challenged. Preclinical and clinical observational evidence suggests loss of efficacy and lack of safety of older RBC units, especially in more vulnerable populations such as critically ill children. Because there is a belief that shorter storage will improve outcomes, some physicians and institutions systematically transfuse fresh RBCs to children. Conversely, the standard practice of blood banks is to deliver the oldest available RBC unit (first-in, first-out policy) in order to decrease wastage.Methods/designThe ABC PICU study, is a double-blind superiority trial comparing the development of “New or Progressive Multiple Organ Dysfunction Syndrome” (NPMODS) in 1538 critically ill children randomized to either transfusion with RBCs stored for ≤ 7 days or to standard-issue RBCs (oldest in inventory). Patients are being recruited from 52 centers in the US, Canada, France, Italy, and Israel.DiscussionThe ABC PICU study should have significant implications for blood procurement services. A relative risk reduction of 33% is postulated in the short-storage arm. If a difference is found, this will indicate that fresher RBCs do improve outcomes in the pediatric intensive care unit population and would justify that use in critically ill children.If no difference is found, this will reassure clinicians and transfusion medicine specialists regarding the safety of the current system of allocating the oldest RBC unit in inventory and will discourage clinicians from preferentially requesting fresher blood for critically ill children.Trial registrationClinicalTrials.gov, ID: NCT01977547. Registered on 6 November 2013.

Clinical characteristics and prognosis of bacteraemia during postoperative intra-abdominal infections

BackgroundBloodstream infections of abdominal origin are usually associated with poor prognosis. We assessed the clinical and microbiological characteristics of critically ill patients admitted to the intensive care unit (ICU) for postoperative intra-abdominal infection (PIAI) and analysed the influence of bacteraemia on their outcome.MethodsAll consecutive PIAI patients admitted to the ICU between 1999 and 2014 were prospectively analysed. Bacteraemic patients (at least one positive blood culture in the 24 h preceding/following surgery) were compared with non-bacteraemic patients. Demographic characteristics, underlying disease, severity scores at the time of reoperation, microbiological results, therapeutic management, outcome, and survival were recorded. Results are expressed as median (interquartile range (IQR)) or proportions.ResultsOverall, 343 patients (54% male, 62 (49–73) years old) with PIAI were analysed, including 64 (19%) bacteraemic patients. Immunosuppression and cancer were more frequent in bacteraemic patients (p < 0.001 in both cases). No difference between groups was observed for the characteristics of initial surgery. Time to reoperation, site, and cause of PIAI were similar in both groups. At the time of reoperation, Sequential Organ Failure Assessment (SOFA) score was higher in bacteraemic patients (8 (6–10) versus 7 (4–10); p < 0.05). A predominance of Gram-positive (34%) and Gram-negative (47%) bacteria were recovered from blood cultures (polymicrobial bacteraemia in 9 (14%) patients and bacteraemia involving multidrug-resistant organisms in 14 (22%) patients). In multivariate analysis, risk factors for bacteraemia were immunosuppression or cancer, high SOFA score, and E. coli in peritoneal samples. Bacteraemia did not impact the management (with similar results for the adequacy of antibiotic therapy, anti-infective agents used, de-escalation or duration of therapy in both groups). Neither hospital mortality nor morbidity criteria differed between groups. Risk factors for mortality in multivariate analysis were urgent initial surgery, high Simplified Acute Physiology Score (SAPS) II score and documented antifungal therapy, but not perioperative bacteraemia.ConclusionsIn this ICU population, bacteraemia did not change the overall management of patients with PIAI. Our data suggest that bacteraemic patients do not require a specific management.

Abstract P-503: REPORTING AND MEASUREMENT OF PHYSICAL REHABILITATION INTERVENTIONS IN PEDIATRIC CRITICAL CARE: A SCOPING REVIEW

Aims & Objectives: Physical rehabilitation (PR) research in critically ill patients is of growing interest. The objective of this scoping review was to evaluate PR research in the pediatric (PICU) and neonatal (NICU) intensive care unit populations, including how PR interventions were reported and measured. Methods We searched 5 databases (from inception to May 2016) for prospective studies evaluating PR interventions in critically ill children. Screening and data abstraction was conducted in duplicate. Quality of reporting was assessed using standardized tools. Completeness of PR intervention reporting was assessed using the Consensus on Exercise Reporting Template (CERT). Results From 58,839 citations, 1,284 full-texts were screened for eligibility, and 21 studies enrolling 1,692 children and neonates were included. All were single-centered studies; 12 (57.1%) were conducted in the PICU and 9 (42.8%) in NICU. Median [Q1, Q3] sample size was 45 [19,87]. Twelve (57.1%) were randomized controlled trials, 2 (9.5%) non-randomized trials, and 7 (33.3%) prospective single-arm trials. Types of PR interventions studied are summarized in Table 1. Authors reported 55.1% (374/679) of all CERT items. Of 8 CERT items critical for PR intervention replication, the best reported (%) were decision rules for starting level of exercise (87.5%), and frequency (80.0%); the poorest were adherence measurement (5.0%), and fidelity of intervention delivery (7.5%).Conclusions In over 50 years of published research, there have been only 21 PR studies in critically ill children. These studies have not reported PR interventions comprehensively. A standardized reporting framework for PR interventions, like CERT, could improve design and reporting in future PR studies.

Clinical Pharmacist Impact on Intensive Care Unit Delirium: Intervention and Monitoring.

Purpose: The purpose of this study was to determine the impact of pharmacist monitoring with a clinical decision support system (CDSS) on clinical outcomes related to intensive care unit (ICU) delirium. Methods: This was a single-center, before-and-after study. This study compares patient outcomes of the preintervention group, which is the standard of care of pharmacist rounding, and the intervention group of pharmacy rounding with the CDSS rules. Using a CDSS, specific delirium risk factor rules were created to alert pharmacists to patients who have an increased risk of developing ICU delirium. Patients were included in the study if they were ⩾18 years of age, admitted to the trauma intensive care unit (TICU), and had one of the CDSS rule alerts. The CDSS notified pharmacists in real time to patients in the intervention group that met these criteria to provide timely recommendations in an effort to prevent ICU delirium. Results: Compared with the preintervention group receiving the standard of care (n = 28), the intervention CDSS group (n = 33) had a nonsignificant trend in decreased incidence of delirium (33.3% vs 24.1%, P = .45), ICU length of stay (LOS) (10.11 vs 7.55 days, P = .26), and ventilator duration (7.11 vs 5.03 days, P = .26). The intervention group had a significantly shorter hospital LOS (14.74 vs 9.98 days, P = .04). There was a nonsignificant increase in mortality with the intervention group from nondelirium causes (24.2% vs 7%, P = .07). Conclusion: The utilization of a CDSS by clinical pharmacists to monitor for delirium-specific risk factors led to a significantly shorter hospital LOS. Further studies using this model are warranted to see the impact on the ICU population.

MicroDAIMON study: Microcirculatory DAIly MONitoring in critically ill patients: a prospective observational study

BackgroundUntil now, the prognostic value of microcirculatory alterations in critically ill patients has been mainly evaluated in highly selected subgroups. Aim of this study is to monitor the microcirculation daily in mixed group of Intensive Care Unit (ICU)-patients and to establish the association between (the evolution of) microcirculatory alterations and outcome.MethodsThis is a prospective longitudinal observational single-centre study in adult patients admitted to a 12-bed ICU in an Italian teaching hospital. Sublingual microcirculation was evaluated daily, from admission to discharge/death, using Sidestream Dark Field imaging. Videos were analysed offline to assess flow and density variables. Laboratory and clinical data were recorded simultaneously. A priori, a Microvascular Flow Index (MFI) < 2.6 was defined as abnormal. A binary logistic regression analysis was performed to evaluate the association between microcirculatory variables and outcomes; a Kaplan–Meier survival curve was built. Outcomes were ICU and 90-day mortality.ResultsA total of 97 patients were included. An abnormal MFI was present on day 1 in 20.6%, and in 55.7% of cases during ICU admission. Patients with a baseline MFI < 2.6 had higher ICU, in-hospital and 90-day mortality (45 vs. 15.6%, p = 0.012; 55 vs. 28.6%, p = 0.035; 55 vs. 26%, p = 0.017, respectively). An independent association between baseline MFI < 2.6 and outcome was confirmed in a binary logistic analysis (odds ratio 4.594 [1.340–15.754], p = 0.015). A heart rate (HR) ≥ 90 bpm was an adjunctive predictor of mortality. However, a model with stepwise inclusion of mean arterial pressure < 65 mmHg, HR ≥ 90 bpm, lactate > 2 mmol/L and MFI < 2.6 did not detect significant differences in ICU mortality. In case an abnormal MFI was present on day 1, ICU mortality was significantly higher in comparison with patients with an abnormal MFI after day 1 (38 vs. 6%, p = 0.001), indicating a time-dependent significant difference in prognostic value.ConclusionsIn a general ICU population, an abnormal microcirculation at baseline is an independent predictor for mortality. In this setting, additional routine daily microcirculatory monitoring did not reveal extra prognostic information. Further research is needed to integrate microcirculatory monitoring in a set of commonly available hemodynamic variables.Trial registration NCT 02649088, www.clinicaltrials.gov. Date of registration: 23 December 2015, retrospectively registered

The intensive care unit course and outcome in acute-on-chronic liver failure are comparable to other populations

Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation of cirrhosis, development of organ failure and high short-term mortality. Whether the outcome in patients admitted to the intensive care unit (ICU) with ACLF differs from other ICU populations is unknown. We compared the clinical course and host response in ICU patients with or without ACLF, matched for baseline severity of illness scores and characteristics. From the large prospective EPaNIC randomized control trial database (n = 4,640), 133 patients were identified with cirrhosis of whom 71 fulfilled the Chronic Liver Failure Consortium criteria for ACLF. These patients were matched for type and severity of illness and demographics to 71 septic and 71 medical ICU patients from the same database without chronic liver disease. Clinical, biochemical and outcome parameters were compared in this cohort study of 213 patients. In a subset of 100 patients, day 1 serum cytokines were quantified. The outcome of ACLF, when compared to septic or medical ICU patients, matched for baseline parameters of illness severity, was similar regarding length of ICU stay, development of new infections, organ failure and septic shock. ICU, hospital and 90-day mortality were similar between the groups. C-reactive protein and platelet levels were lower in patients with ACLF throughout the first week. Cytokines, including IL-10, IL-1β, IL-6, and IL-8, were similarly elevated in ACLF and septic ICU patients on day 1. However, TNF-α levels were higher in patients with ACLF. Patients with ACLF admitted to the ICU showed comparable clinical and ICU outcomes as ICU patients without chronic liver disease, but with similar baseline severity of illness characteristics. This suggests that ICU admission criteria should not be different in ACLF populations. Liver function may abruptly deteriorate in patients with chronic liver disease with cirrhosis, often resulting in these patients being admitted to an intensive care unit (ICU) with organ failure. Previous studies have indicated that this sudden deterioration, called acute-on-chronic liver failure is associated with very high mortality rates, which often resulted in deferred ICU care because of a perception of futility. Our study now shows that the ICU course and outcome are not different when patients with acute-on-chronic liver failure are compared to other ICU patients matched for severity of illness. This demonstrates that patients with acute-on-chronic liver failure deserve the same ICU care given to other ICU populations.

Acquired Infection and Antimicrobial Utilization During Initial NICU Hospitalization in Infants With Congenital Diaphragmatic Hernia.

In addition to substantial medical and surgical intervention, neonates with congenital diaphragmatic hernia often have concurrent concerns for acquired infection. However, few studies focus on infection and corresponding antimicrobial utilization in this population. The Children's Hospital Neonatal Database was queried for congenital diaphragmatic hernia infants hospitalized from January 2010 to February 2016. Patient charts were linked to the Pediatric Health Information Systems database. Descriptive clinical data including delivery history, cultures sent, diagnosed infection, antimicrobial use and outcomes were reported. A total of 1085 unique patients were identified after data linkages; 275 (25.3%) were born at <37 weeks' gestation. Bacteremia at delivery (2/1085) and in the first 7 days of life (8/1085) was less common than later infection, but 976 patients (89.9%) were treated with antibiotics. Median number of days on antibiotics was 6 [3,11] for those without a documented infection and 21 [13,36] for those with positive cultures. Incidence of urinary tract infection, bacteremia and pneumonia increased significantly over time and was most common after 28 days. Antibiotic use, conversely, decreased over time (92% of infants in week 1 to 44% in week 4 and beyond). Although culture positivity increased with age, risk of these selected infections was relatively low for a population in neonatal intensive care unit. An important mismatch is observed between culture negativity and high rates of antibiotic utilization. These data identify opportunities for antibiotic stewardship quality improvement programs.