Intensive Care Unit Mortality Research Articles

Systemic Postnatal Corticosteroids, Bronchopulmonary Dysplasia, and Survival Free of Cerebral Palsy

ImportanceSystemic postnatal corticosteroids have been shown to reduce rates of bronchopulmonary dysplasia (BPD) in infants born preterm, but both corticosteroids and BPD are associated with cerebral palsy.ObjectiveTo describe how the association between systemic postnatal corticosteroids and survival free of cerebral palsy varies with the risk of BPD in infants born preterm, and if the association differs between dexamethasone and hydrocortisone, or with age at starting treatment.Design, Setting, and ParticipantsThis comparative effectiveness research used weighted meta-regression analysis of eligible randomized clinical trials (RCTs) of systemic postnatal corticosteroids reported from June 1989 through March 2022 that included rates of all of BPD, mortality, and cerebral palsy in neonatal intensive care units in 10 countries. Infants born preterm at risk of BPD were included. Data were analyzed from April and July 2024.InterventionsSystemic dexamethasone or hydrocortisone.Main Outcomes and MeasuresType and timing of corticosteroid, control group rate of BPD, and risk difference in survival free of cerebral palsy between corticosteroid and control arms.ResultsTwenty-six RCTs with data on 3700 randomized infants were eligible; 18 (69%) investigated dexamethasone and 8 (31%) hydrocortisone; 12 (46%) started treatment in the first week after birth. There was evidence for a differential association of the type of corticosteroid with the effect of systemic dexamethasone on survival free of cerebral palsy and the risk of BPD in control groups (interaction coefficient, 0.54; 95% CI, 0.25-0.82; P = .001). For dexamethasone, for every 10–percentage point increase in the risk of BPD, the risk difference for survival free of cerebral palsy increased by 3.74% (95% CI, 1.54 to 5.93; P = .002). Dexamethasone was associated with improved survival free of cerebral palsy at a risk of BPD greater than 70%. Conversely, dexamethasone was associated with harm at a risk of BPD less than 30%. There was some evidence for a negative association with hydrocortisone, with possible benefit with risk of BPD less than 30%. There was no strong evidence for a differential effect of timing among those treated with dexamethasone (interaction coefficient, 0.13; 95% CI, −0.04 to 0.30; P = .14).Conclusions and RelevanceThe findings suggest that dexamethasone (compared with control) was associated with improved rates of survival free of cerebral palsy in infants at high risk of BPD but should be avoided in those at low risk. A role for hydrocortisone is uncertain.

Association between the use of loop diuretics and prognosis in critically ill patients with acute kidney injury: a retrospective propensity score-matched cohort study.

The role of loop diuretics in patients with acute kidney injury (AKI) is controversial. This study examined the association between the use of loop diuretics and prognosis in critically ill patients with AKI. This study used data from the medical information mart for the intensive care IV database. Adult critically ill patients with AKI were included in the analysis. Patients were partitioned into two groups based on their use of loop diuretics in the ICU, and potentially confounding variables between the two groups were balanced using propensity score matching (PSM). We used time-dependent Cox proportional hazards regression, logistic regression, and Hodges-Lehman estimator to assess the impact of loop diuretics on all-cause mortality, renal replacement therapy (RRT) use, and the length of hospital stay, respectively. This study included a cohort of 19,671 patients. After PSM, both groups consisted of 6200 patients. The use of loop diuretics was associated with a lower risk of in-hospital mortality (HR, 0.672; 95% CI 0.597-0.757; P < 0.001), lower in-ICU mortality (HR, 0.375; 95% CI 0.315-0.446; P < 0.001), and lower odds of in-hospital RRT (OR, 0.472; 95% CI 0.400-0.555; P < 0.001). A sensitivity analysis using the original cohort (HR, 0.624; 95% CI 0.561-0.693; P < 0.001) and weighted cohort (HR, 0.654; 95% CI 0.582-0.736; P < 0.001) also demonstrated lower in-hospital all-cause mortality. The use of loop diuretics is associated with a substantial reduction in mortality among critically ill patients with AKI.

Bacterial Superinfections in Critically Ill Patients With SARS-CoV-2 Infection: A Retrospective Cohort Study.

There is a considerable gap in the current evidence concerning the prevalence of superinfections among critically ill patients with SARS-CoV-2 infection in Saudi Arabia. We sought to determine the prevalence of bacterial superinfections following the initiation of antibiotic therapy in critically ill patients with SARS-CoV-2 infection. A retrospective observational study that included patients with SARS-CoV-2 infection admitted to the intensive care unit (ICU) for at least 24 hours and received empirical antibiotic therapy. The primary outcome was the rate of bacterial superinfections occurring at least 48 hours after the initiation of antibiotics. ICU-related outcomes and complications were compared between subgroups with and without superinfections and amongst the two most frequently used antibiotic regimens. A total of 230 patients were included in our study. Superinfections developed in 40 (17.4%) patients, with the median time from the first dose of antibiotic to the emergence of superinfection of 17.6 days (IQR 9.8-29.2). Patients with superinfections had longer median ICU stays [ 27.1 days(IQR 15.2-43.3) versus 7.1 days(IQR 3.8-11.8); P < 0.001], developed more complications [92.5% versus 52.6%; P < 0.001], and had higher ICU mortality [45.0% versus 22.1%; P = 0.0034] compared to patients without superinfections. The two most frequently prescribed antibiotic regimens were piperacillin/tazobactam plus levofloxacin (53.9%) and meropenem plus levofloxacin (19.7%). Although there was no significant difference in the rate of superinfections [15.3% versus 26.7%; P = 0.09] between the two groups, patients in the superinfections group who received piperacillin/tazobactam plus levofloxacin developed more complications [94.7% versus 91.7%; P < 0.001] and had a higher ICU mortality [57.9% versus 50%; P < 0.001]. Superinfections occurred at a higher rate in critically ill patients with SARS-CoV-2 infection post empirical antibiotics initiation. The use of piperacillin/tazobactam plus levofloxacin was associated with an increase in the rate of complications and higher ICU mortality. Larger multicenter studies are needed to confirm these results.

Intensive care unit admissions following enhanced recovery video-assisted thoracoscopic surgery lobectomy.

Video-assisted thoracoscopic surgery (VATS) lobectomy combined with enhanced recovery after surgery (ERAS) protocols has improved postoperative outcomes, yet concerns persist regarding complications and readmissions. Limited research has explored intensive care unit (ICU) admissions and outcomes within this context. This study aimed to analyze ICU admissions following VATS lobectomy within an established ERAS protocol. Consecutive patients who underwent VATS lobectomy between 2018-2023 were included. Patient data were obtained from our prospective institutional database, while ICU data were extracted from electronic patients' records. Of 2099 patients included, 48 (2.3%) required ICU admission. Median-age was 70 (IQR : 64-76), with ICU patients being older and predominantly male (73%). Overall 30-day-mortality was 1.0% with an ICU mortality of 31%. Multiple logistic regression revealed significant associations between ICU admission and male gender (p = <0.001), diabetes mellitus (p = 0.026), heart failure (p = 0.040), DLCO%(0.013). Median time to ICU admission was 4 days (IQR : 2-10). Respiratory failure was the primary reason for ICU admission (60%). Severe surgical complications accounted for 8.3% of all ICU-admissions. In an ERAS setting, the incidence of ICU admission following VATS lobectomy was 2.3%, with a mortality rate of 31%. Respiratory failure was the leading cause of ICU admission.

The Roles of Vitamin D Levels, Gla-Rich Protein (GRP) and Matrix Gla Protein (MGP), and Inflammatory Markers in Predicting Mortality in Intensive Care Patients: A New Biomarker Link?

Objectives: Identifying reliable biomarkers to predict mortality in critically ill patients is crucial for optimizing management in intensive care units (ICUs). Inflammatory and metabolic markers are increasingly recognized for their prognostic value. This study aims to evaluate the association of various inflammatory and metabolic markers with ICU mortality. Methods: This prospective observational study was conducted from January 2023 to January 2024 in the City Hospital’s ICU. A total of 160 critically ill patients were enrolled. Laboratory parameters, including white blood cell (WBC) count, red cell distribution width (RDW), platelet count, neutrophil count, mean platelet volume (MPV), monocyte count, lymphocyte count, procalcitonin (PCT), C-reactive protein (CRP), calcium (Ca++), and vitamin D levels, were analyzed. Additionally, ratios such as the platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), systemic inflammatory index (SII), and pan-immune-inflammation value (PIV) were calculated. Plasma levels of Gla-rich protein (GRP) and dephosphorylated uncarboxylated matrix Gla protein (dp-ucMGP) were measured using ELISA. Results: The mean age of the patients included in the study was 60.5 ± 15.8 years. Cardiovascular disease was present in 72 patients (45%), respiratory system disease in 58 (36%), and chronic kidney disease (CKD) in 38 (24%). Additionally, 61 patients (38%) had diabetes, and 68 (42%) had hypertension. Inflammatory markers, including PLR, NLR, and PIV, were all significantly higher in non-survivors, while calcium and vitamin D levels were lower (p &lt; 0.05). Higher WBC, RDW, neutrophil count, PLR, NLR, PIV, CRP, procalcitonin, GRP, and dp-ucMGP levels were positively correlated with longer hospital stays and increased mortality. In contrast, platelet and lymphocyte counts were negatively correlated with both outcomes (p &lt; 0.05). Vitamin D levels showed an inverse relationship with both hospital stay and mortality, indicating that lower levels were associated with worse outcomes (p &lt; 0.05). In multiple logistic regression analysis, elevated WBC count (OR = 1.20, p = 0.02), RDW (OR = 1.35, p = 0.01), neutrophil count (OR = 1.25, p = 0.01), MPV (OR = 1.20, p = 0.02), PLR (OR = 1.30, p = 0.01), NLR (OR = 1.40, p = 0.001), PIV (OR = 1.50, p = 0.001), CRP (OR = 1.32, p = 0.01), procalcitonin (OR = 1.45, p = 0.001), GRP (OR = 1.40, p = 0.001), and dp-ucMGP (OR = 1.30, p = 0.001) levels were significantly associated with increased mortality. Conclusions: Inflammatory and metabolic markers, particularly NLR, PLR, PIV, GRP, and dp-ucMGP, are strong predictors of mortality in ICU patients. These markers provide valuable insights for risk stratification and early identification of high-risk patients, potentially guiding more targeted interventions to improve outcomes.

A Retrospective Observational Study Evaluating COVID-19 Mortality and Morbidity in a Rural ICU Among People Over and Under 65

A Retrospective Observational Study Evaluating COVID-19 Mortality and Morbidity in a Rural ICU Among People Over and Under 65

Abstract 4137689: Artificial Intelligence Assessment of Diastolic Dysfunction by Electrocardiogram: Outcomes in Cardiac Intensive Care Unit Patients

Background: Left ventricular diastolic dysfunction (LVDD) predicts mortality in cardiac intensive care unit (CICU) patients. A novel artificial intelligence enhanced electrocardiogram (AIECG) algorithm can predict LVDD and mortality in general populations but has not been examined in the cardiac intensive care unit (CICU). We aim to assess if LVDD by AI-ECG is associated with in-hospital and one-year mortality in CICU patients. Methods: In this retrospective cohort study, we included consecutive unique adults admitted to the Mayo Clinic CICU from 2007 to 2018 with an admission AIECG, which AI assigned LVDD grade (0 to 3). Medial mitral E/e’ ratio &gt;15 on transthoracic echocardiogram (TTE) defined elevated filling pressures. AIECG and TTE assessment of LVDD were used to assign patients to four groups based on TTE as gold standard: true and false negative, and true and false positive. In-hospital mortality was evaluated using multivariable logistic regression. One-year survival was evaluated using Kaplan-Meier curves and multivariable Cox proportional-hazards. Results: We included 11,868 patients (median age 69.5 years, 37.7% females); 48% had heart failure and 44% had acute coronary syndromes. AIECG LVDD grades were: grade 0 (normal), 33%; grade 1, 7%; grade 2, 39%; grade 3, 21%. In-hospital (adjusted OR) and one-year (adjusted HR) mortality increased in each higher AIECG LVDD grade (Figure A/B), before and after adjustment including TTE measurements. Patients with grade 2-3 LVDD by AIECG and medial mitral E/e’ ratio &gt;15 by TTE (true positive) had the highest in-hospital (adjusted OR 2.5 [1.7-3.9]) and one-year (adjusted HR 1.9 [1.5-2.5]) mortality (Figure C/D), and mortality was elevated similarly in patients with either grade 2-3 LVDD by AIECG (false positive) or medial mitral E/e’ ratio &gt;15 by TTE (false negative). Conclusions: The AIECG LVDD grade was strongly associated with in-hospital and one-year mortality in CICU patients, even after adjusting for clinical variables and TTE measurements. Patients with concordant AIECG and TTE for elevated filling pressures (true positive) were at highest risk.

Abstract 4113420: Assessing the Clinical Impact of Cardiac Intensivists in Cardiac Intensive Care Units.: Results from the RESCUE registry

Background: Presence of dedicated intensive care unit physicians is associated with reduced intensive care unit mortality. However, there is limited information regarding the impact of cardiac intensivists in cardiac intensive care units. Research Questions: What is the role of cardiac intensivists in influencing clinical outcomes for adult patients admitted to cardiac intensive care units? Aims: To investigate the association between cardiac intensivist-directed care and clinical outcomes in adult patients admitted to cardiac intensive care units. Methods: This retrospective study used data from the SMART-RESCUE registry, which is a multicenter, retrospective, and prospective registry of patients presenting with cardiogenic shock. The study involved 1,247 patients enrolled from January 2014 to December 2018 at 12 tertiary centers in Korea. These patients, who were suffering from cardiogenic shock, were divided into two groups depending on whether their care involved a cardiac intensivist. Results: The study found that the all-cause mortality rate was 33.6%. The in-hospital mortality rate was significantly lower in the group managed by cardiac intensivists (25.4%) compared to the group without (40.1%). Similarly, cardiac death rates were lower in the cardiac intensivist group (20.5%) than in the non-cardiac intensivist group (35.4%). In patients undergoing extracorporeal membrane oxygenation, mortality at centers with cardiac intensivists was 38.0%, compared to 62.2% at centers without. The use of dopamine was lower and norepinephrine use was higher and the vasoactive-inotropic score was lower in the cardiac intensivist group. Conclusion: Cardiac intensivist involvement in patient care within cardiac intensive care units was associated with a reduction in in-hospital mortality and administration of vasopressors and inotropes according to cardiogenic shock guidelines, indicating a beneficial effect on clinical outcomes.

Abstract 4138252: Association between Pressure-Adjusted Heart Rate and Mortality in Cardiogenic Shock

Introduction: Among patients with cardiogenic shock (CS), high right atrial pressure (RAP) and low mean arterial pressure (MAP) are associated with in-hospital mortality. Pressure-adjusted heart rate (PAHR), defined as heart rate * RAP-to-MAP ratio (HR * [RAP/MAP]), integrates these parameters and has been used to identify cardiovascular dysfunction in critical illness. Higher PAHR values associate with higher surgical ICU mortality, but the prognostic significance of PAHR has not been assessed in cardiac intensive care unit (CICU) patients with CS. Hypothesis: We hypothesized that higher PAHR values are associated with higher risk of in-hospital mortality in patients with CS. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multinational registry of CICUs coordinated by the TIMI Study Group. Among CS admissions (2018-2023) undergoing invasive hemodynamic assessment within 24h of CICU admission, we calculated PAHR (in bpm) and assessed its relationship with in-hospital mortality. Patients on temporary mechanical circulatory support were excluded. Odds ratios were adjusted for age, sex, vasoactive-inotropic score (VIS), SCAI stage, and preceding cardiac arrest. Subgroup analyses stratifying by CS subtype were performed. Results: Among the 1411 CS admissions in the analysis cohort (mean age 61 years, 31% women), 18% had AMI-CS, 75% had HF-CS, and 7% had secondary CS. At the time of assessment (median 1.4h after CICU admission), 75% were on vasoactive support (median VIS 3.8). Median HR was 92 (Q1-Q3 77-109) bpm, RAP 15 (Q1-Q3 10-19) mmHg, MAP 75 (Q1-Q3 67-87) mmHg, and PAHR 17 (Q1-Q3 11-24) bpm. A stepwise gradient of higher in-hospital mortality with increasing PAHR values (p-trend &lt;0.001; Fig ) was observed. In adjusted models, a higher PAHR was associated with higher in-hospital mortality (aOR per 10-bpm, 1.35 [95% CI, 1.15-1.58]), and had stronger prognostic associations with mortality than its individual hemodynamic components (Fig) . Conclusion: Higher PAHR is strongly associated with in-hospital mortality in CS patients. PAHR, a simple parameter which is readily calculable without needing a pulmonary artery catheter, may aid in identifying CS patients at higher risk of death.

Abstract 4123371: Hyperoxia is not a significant predictor of ICU mortality and is likely a surrogate parameter for reduced native cardiac function in patients supported with VA-ECMO

Intro: Hyperoxia has been associated with adverse outcomes in VA-ECMO patients. Whether hyperoxia represents a mechanism of mortality or is a surrogate for worse cardiac function is unknown. Aim: To determine patient characteristics, lab values, and hemodynamic parameters associated with increased mortality in VA-ECMO patients. Methods: Single-center retrospective cohort study at UCSF in VA-ECMO patients (2020-2023). Patients were categorized into 3 groups: Dead, Advanced Therapy-Free Survivors, and Advanced Therapy Survivors (survived to ICU discharge with LVAD or heart transplant). Wilcox rank sum and two sample proportion tests were performed. In-hospital mortality was evaluated using multiple logistic regression. Results: Of 179 patients, 87 died and 92 survived to ICU discharge. Of the survivors, 22 received advanced therapies. Compared to Advanced Therapy-Free Survivors, Dead patients had higher PaO2 levels (297[95% CI,164-400], p = 0.01). Dead and Advanced Therapy Survivors groups had similarly high PaO2 levels, but the latter group showed less acidosis and were more likely to have HFrEF (59%; 13/22; p = 0.02). ECMO support and VIS scores were similar. The multivariate model showed PaO2 is not associated with mortality (adjusted OR, 1.002 [95% CI, 0.99-1.004]; p = 0.131). Conclusion: Hyperoxia was associated with both death and advanced therapies, but did not predict mortality in a multivariate model. Advanced therapy survivors and patients that died were more likely to have HFrEF, suggesting that high PaO2 at cannulation reflects a proximal mixing cloud due to weak native cardiac function. Future work will analyze ECHO parameters to examine the association between hyperoxia and reduced cardiac output in VA-ECMO patients.

Evolution of the oxyhemoglobin dissociation curve in COVID-19 related ARDS patients

IntroductionSevere hypoxemia is the leading cause of admission in intensive care (ICU) in patients with COVID-19 related acute respiratory distress syndrome (ARDS). In these patients, several studies reported a left shift of the oxyhemoglobin dissociation curve associated with a lower mortality. However, these results are conflicting, as these studies include few patients and often no control groups. Moreover, the calculation of P50, representing the PaO2 value at which 50% of hemoglobin is saturated, is not corrected for factors known to influence it (pH, PaCO2 or temperature). For all of these reasons, we compared the corrected P50 between ICU patients with severe COVID-19 related ARDS on mechanical ventilation or not, and ARDS from other causes. We investigated the evolution of the corrected P50 during the first 3 days of ICU and its relationship with ICU mortality.Methods and PatientsWe retrospectively calculated the corrected P50 in three groups of patients: intubated and mechanically ventilated COVID-19 related ARDS, non-intubated COVID-19 related ARDS and intubated patients with ARDS due to other infectious causes. The corrected P50 was calculated, on the worst blood gas analysis on days 1 and 3 of ICU admission, by the formula of Hill but modified by Dash et al., controlled for pH, PaCO2 and temperature. We collected ICU mortality.Results463 blood gas analysis at days 1 and 3 from 214 ICU COVID-19 related ARDS patients (114 with intubation and 100 without) and 35 ICU patients with ARDS from other causes were analyzed. All patients were severely hypoxemic: PaO2/FiO2 of 76 [58-108] mmHg for intubated COVID-19, 79 [60-108] mmHg for non-intubated COVID-19 and 142 [78-197] mmHg for the third group (p &amp;lt; 0.001). The mortality rate was higher in intubated COVID-19 related ARDS patients (44.7 versus 14 versus 37% in ARDS from other causes; p &amp;lt; 0.001). The corrected P50 was significantly lower in COVID-19 patients, especially in non- intubated patients (21.2 [18.8–25.2] mmHg vs. 25.5 [19.2–30.3] mmHg in intubated patients; compared to ARDS from other causes: 27.2 [23.3-35.4] mmHg; p &amp;lt; 0.001. The corrected P50 does not change over the first 3 days, except for the non intubated COVID-19 related ARDS and is not correlated with ICU mortality (odds ratio = 0.98 [0.95-1.03]; p = 0.51), in contrast of PaO2/FiO2 and ICU gravity scores.ConclusionThe oxyhemoglobin dissociation curve at ICU admission was left shifting in severe COVID-19 related ARDS patients regardless of the type of ventilation. This deviation increases the third day only in non-intubated COVID-19 related ARDS and was not related to the outcome.

Assessing COVID-19 Vaccine Effectiveness and Risk Factors for Severe Outcomes through Machine Learning Techniques: A Real-World Data Study in Andalusia, Spain.

COVID-19 vaccination has become a pivotal global strategy in managing the pandemic. Despite COVID-19 no longer being classified as a Public Health Emergency of International Concern, the virus continues affecting people worldwide. This study aimed to evaluate risk factors and vaccine effectiveness on COVID-19-related hospital admissions, intensive care unit (ICU) admission and mortality within the Andalusian population throughout the pandemic. From March 2020 to April 2022, 671,229 individuals, out of 9,283,485 with electronic health records in Andalusia, experienced SARS-CoV-2 infection and were included in the analysis. Data on demographics, medical history, vaccine administration, and hospitalization records were collected. Associations between medical history, COVID-19 vaccines, and COVID-19 outcomes were assessed. Our study identified 48,196 hospital admissions, 5,057 ICU admissions, and 11,289 deaths linked to COVID-19. Age, male sex, and chronic diseases were identified as risk factors, while the COVID-19 vaccine demonstrated protective effects, although with reduced effectiveness during the omicron variant period. However, the risk for these outcomes increased over time after receiving the last vaccine dose, particularly after six months, especially among those aged 60 or older. The global health challenge of COVID-19 persists, marked by emerging variants with higher virulence and severity, particularly among the unvaccinated and those beyond six months post-vaccination, especially those aged 60 and above. These findings highlight the need for robust surveillance systems targeting new variants and administering booster doses, particularly for individuals aged 60 or older with underlying health conditions, to mitigate the global burden of COVID-19.

Long-term results of intensive care patients with post-intubation tracheal stenosis: 7 years follow-up.

Benign tracheal stenosis (TS) is a potentially life-threatening condition caused by iatrogenic events resulting from endotracheal intubation and tracheostomy. The study aimed to determine the clinical characteristics, management, and long-term outcomes of patients with simple or complex post-intubation tracheal stenosis (PITS) who were admitted to the intensive care unit (ICU). Retrospective analysis of patients admitted to the ICU between June 2016 and June 2022 and diagnosed with PITS were performed until June 2023. 76 patients (mean age 54.9 ± 17.3%, 63.2% male, 61.8% complex stenosis) admitted to the ICU were analysed. The diagnosis of PITS was made by fiberoptic bronchoscopy (FOB) in 53.9% and computed tomography (CT) in 46.1%. The most common location of stenosis was the upper trachea area (57.9%, n = 44). The median stenosis length of the TS was 1.9cm (median 2cm for complex stenosis, 1cm for simple stenosis, p < 0.001). Complex stenosis was associated with longer intubation time and multiple intubation history (p = 0.011, p = 0.028). At the same; complex stenosis was associated with prolonged and high stenosis percentage (p < 0.001). While dilatation and cryotherapy were sufficient for treatment in all patients with simple stenosis, the stent was applied to 34% patients with complex stenosis. Recurrence was higher in complex stenosis after bronchoscopic procedure (complex stenosis 95.7%, simple stenosis 17.2%). 19 (25%) patients required surgical operation, and all of these patients had complex stenosis (p < 0.001). Median follow-up was 33 months for simple stenosis and 34 months for complex stenosis. ICU length of stay (LOS) was longer in patients with complex stenosis. There was no statistically significant difference between TS classes in terms of ICU mortality (p = 0.466), 1-year mortality (p = 0.951), and mortality during follow-up (p = 0.608). PITS is a challenging situation in ICU patients. In patients with a preliminary diagnosis of PITS, bronchoscopy should be performed without delay, and it should be known that interventional bronchoscopy is not only a diagnostic tool but an effective strategy in treatment management after the diagnosis is finalised. The advantage of interventional bronchoscopy is that it alleviates symptoms that necessitate hospitalisation in the ICU and eliminates the need for ICU of patients.

Prevalence, Risk Factors, and Mortality of New-Onset Atrial Fibrillation in Mechanically Ventilated Critically Ill Patients

Background/Objectives: Critically ill patients admitted to the intensive care unit (ICU) frequently develop new-onset atrial fibrillation (NOAF) due to numerous risk factors. While NOAF has been associated with increased mortality, it remains unclear whether it serves merely as a marker of illness severity or directly contributes to adverse outcome. This study aimed to determine the incidence and risk factors for NOAF in a homogenized population of mechanically ventilated patients at ICU admission, excluding well-established predisposing factors. Additionally, we examined the impact of NOAF on mortality in this context. Methods: We prospectively studied consecutive patients over a 3-year period to identify triggers for NOAF. Factors associated with 30-day mortality during the ICU stay were recorded. Demographic data, medical history, laboratory findings, and the severity of illness at admission were compared between patients who developed NOAF and those remaining in sinus rhythm. In NOAF patients, the course of atrial fibrillation (resolution, persistence, or recurrence) was evaluated during the 30-day ICU stay. Results: Of the 1330 patients screened, 685 were eligible for analysis, with 110 (16.1%) developing NOAF. Septic episodes occurred more frequently in the NOAF group compared to the no-NOAF group (92.7% vs. 58.1%, p &lt; 0.001). Notably, 80% of NOAF patients developed a septic episode concurrently with the atrial fibrillation, often stemming from secondary infections, and 85.3% presented with septic shock. When focusing on patients with at least one septic episode during the 30-day ICU stay, 23.4% of them developed NOAF. Additionally, patients with NOAF were older and had a higher prevalence of hypertension; disease severity at admission was not a triggering factor. Mainly sepsis, but also advanced age, and a history of hypertension remained independent factors associated with its occurrence. Sepsis, primarily, along with advanced age and a history of hypertension, was identified as independent factors associated with the occurrence of NOAF. Mortality was higher in the NOAF group compared to the control group (39 patients (35.5%) vs. 138 patients (24%), p = 0.01). NOAF occurrence, sepsis, disease severity at admission, and age were associated with increased ICU mortality; however, NOAF was not found to be an independent predictor of ICU mortality in multivariate analysis. Instead, sepsis, age, and disease severity at admission remained independent predictors of 30-day mortality. Sinus rhythm was restored in 60.9% of NOAF patients within 48 h, with the improvement or stabilization of sepsis being crucial for rhythm restoration. Conclusions: NOAF is a common complication in intubated ICU patients and is independently associated with sepsis, advanced age, and hypertension. While NOAF is linked to increased ICU mortality, it is more likely a marker of disease severity than a direct cause of death. Sepsis improvement appears critical for restoring and maintaining sinus rhythm.

Dexmedetomidine Attenuates Neuroinflammation-Mediated Hippocampal Neurogenesis Impairment in Sepsis-Associated Encephalopathy Mice through Central α2A-Adrenoceptor.

Sepsis-associated encephalopathy (SAE), one of the common complications of sepsis, is associated with higher ICU mortality, prolonged hospitalization, and long-term cognitive decline. Sepsis can induce neuroinflammation, which negatively affects hippocampal neurogenesis. Dexmedetomidine has been shown to protect against SAE. However, the potential mechanism remains unclear. In this study, we added lipopolysaccharide (LPS)-stimulated astrocytes-conditioned media (LPS-CM) to neural stem cells (NSCs) culture, which were pretreated with dexmedetomidine in the presence or absence of the α2-adrenoceptor antagonist yohimbine or the α2A-adrenoceptor antagonist BRL-44408. LPS-CM impaired the neurogenesis of NSCs, characterized by decreased proliferation, enhanced gliogenesis, and declined viability. Dexmedetomidine alleviated LPS-CM-induced impairment of neurogenesis in a dose-dependent manner. Yohimbine, as well as BRL-44408, reversed the effects of dexmedetomidine. We established a mouse model of SAE via cecal ligation and perforation (CLP). CLP-induced astrocyte-related neuroinflammation and hippocampal neurogenesis deficits, accompanied by learning and memory decline, which were reversed by dexmedetomidine. The effect of dexmedetomidine was blocked by BRL-44408. Collectively, our findings support the conclusion that dexmedetomidine can protect against SAE, likely mediated by the combination of inhibiting neuroinflammation via the astrocytic α2A-adrenoceptor with attenuating neuroinflammation-induced hippocampal neurogenesis deficits via NSCs α2A-adrenoceptor.

Relationship between lactate levels and 28-day mortality in pediatric sepsis: results from the pediatric intensive care database

ObjectiveThis study aimed to investigate the relationship between serum lactate levels at admission to the intensive care unit (ICU) and the clinical outcomes of children with sepsis.MethodsWe used the Pediatric Intensive Care (PIC) database to identify 288 pediatric patients with sepsis. We analyzed the relationship between lactate levels and hospital and ICU mortality in sepsis by establishing a segmented multivariable Cox regression model. We also conducted subgroup analysis as well as analyzed the restricted cubic spline curves.ResultsAfter adjusting for all potential confounding factors, an increase of 1 mmol/L in lactate levels was found to be associated with an 17% rise in the 28-day hospital mortality risk among sepsis patients (HR: 1.17, 95% CI: 1.08–1.27, P = 0.0002). When considering lactate as a categorical variable, the mortality risk of patients with lactate levels ≥ 2.2 mmol/L was significantly increased (HR: 3.61, 95% CI: 1.24–10.54, P = 0.0189). The restricted cubic spline curve analysis revealed a nonlinear correlation between lactate and 28-day mortality, with an inflection point at 2.2 mmol/L. Similar findings were also observed in the assessment of secondary outcomes.ConclusionsOur study demonstrates a non-linear correlation between lactate levels and 28-day mortality in pediatric sepsis, with a critical threshold of 2.2mmol/l for lactate levels in septic patients. Early assessment of lactate levels is recommended for children with sepsis to facilitate prompt intervention and mitigate the risk of fatality.

Comparison of risk-adjusted cumulative quality control charts compared with standardized mortality ratios in critical care.

The optimal method for monitoring intensive care unit (ICU) performance is unknown. We sought to compare process control charts using standardized mortality ratio (SMR), p-charts, and cumulative sum (CUSUM) charts for detecting increases in risk-adjusted mortality within ICUs. Using data from 17 medical-surgical ICUs that included 29,592 patients in Ontario, Canada, we created risk-adjusted p-charts and SMRs on monthly intervals and CUSUM charts. We defined positive signals as any data point that was above the 3-sigma limit (approximating a 99% confidence interval [CI]) on a p-chart, any data point whose 95% CI did not include 1 for the SMR charts, and when a data point exceeded control limits for an odds ratio of 1.5 for CUSUM charts. We simulated increases in mortality of 10%, 30%, and 50% for each ICU to determine the sensitivity of each method. We calculated sensitivity as the number of positive signals divided by the number of ICUs (equal to number of simulated events). Cumulative sum charts generated 31 signals in 12 different ICUs, while p-charts and SMR agreed in 10 and 6 of these signals, respectively, followed by 21 signals from p-charts across 14 ICUs (agreement in 10 of these signals for both CUSUM and SMR) and 15 signals from SMR charts across eight ICUs (agreement from p-charts and CUSUM in 10 and six signals, respectively). The p-chart had a sensitivity of 88% (95% CI, 73 to 104) for a 50% simulated increase in ICU mortality followed by CUSUM at 71% (95% CI, 49 to 102) and SMR at 59% (95% CI, 35 to 82). Performance with lower simulated increases was poor for all three methods. P-charts created with risk-adjusted mortality at monthly intervals are potentially useful tools for monitoring ICU performance. Future studies should consider usability testing with ICU leaders and application of these methods to additional clinical domains.

Epidemiology of Emergency Department Visits for Children With Clinically Significant Cardiovascular Disease.

The aim of the study is to determine the epidemiology, cost, and factors associated with hospital admission, deterioration if hospitalized, and mortality for children with a history of clinically significant cardiovascular disease (CVD) presenting to pediatric emergency departments (EDs). Using the Pediatric Health Information System, we performed a retrospective analysis of ED encounters of children ≤17 years old with clinically significant CVD between 2016 and 2021. Patients were included if they had a cardiovascular complex chronic condition, defined by ICD diagnosis, and procedure codes. We assessed the primary diagnosis, admission rate, ICU transfer rate (as a marker of disease progression), mortality, resource utilization, and costs. We conducted multivariable analyses to identify risk factors for admission, ICU transfer, and mortality. There were 201,551 ED visits (mean 33,592 ± 3354 per year) among 129,938 children with clinically significant CVD. Most ED encounters had a primary diagnosis of a circulatory (21.1%) or respiratory (19.7%) illness. Seventy-six percent of visits had at least one blood test or imaging study conducted. The overall admission rate was 59.7%, with 28.7% admitted to the ICU, and 6.2% transferred to the ICU after the first 24 hours. The median costs for encounters resulting in admission were $13,605 in US 2023 dollars. In multivariable analyses, younger age, a greater number of noncardiac complex chronic conditions, and CVD type were associated with increased odds of admission, ICU transfer after 24 hours, and mortality (all P < 0.05). ED visits for children with clinically significant CVD lead to substantial resource utilization, including frequent hospitalization, ICU level of care, and costs. This baseline data aids in the development of prospective studies to inform the appropriate ED management for children with clinically significant CVD.

Association between the serum albumin–creatinine ratio and 28-day intensive care unit mortality among patients with sepsis: a multicenter retrospective cohort study

IntroductionSepsis is a substantial global health challenge with a considerable disease burden. Despite advancements in sepsis research, the mortality rates associated with this condition remain high. The relationship between the serum albumin-to-creatinine ratio (sACR) and mortality in patients with sepsis remains unclear. Therefore, this study aimed to investigate the association between the sACR and 28-day mortality in intensive care unit (ICU) patients with sepsis.MethodsIn this retrospective cohort study, we used data sourced from the eICU Collaborative Research Database. The primary exposure variable was sACR, and the primary outcome measure was mortality within 28 days after ICU admission. Statistical analyses included univariate and multivariate logistic regression models, generalized additive models, and two-piecewise linear regression models, which were employed to explore non-linear relationships and threshold effects between sACR and mortality.ResultsThe study cohort comprised 9,690 ICU patients with sepsis, with a 28-day mortality rate of 9.99%. The results of the multivariate logistic regression model indicated that elevated sACR levels were significantly associated with a reduced risk of mortality (odds ratio = 0.78, 95% confidence interval: 0.71–0.87, p &amp;lt; 0.001), even after adjusting for potential confounding variables. Curve fitting revealed a non-linear relationship between sACR and 28-day mortality, with an inflection point of 4.79.DiscussionThis study demonstrated that sACR is an independent risk factor for 28-day mortality in ICU patients with sepsis, exhibiting a non-linear negative dose–response relationship and a threshold effect. These findings may serve as early warning indicators in high-risk populations.

Epidemiology, clinical and biological characteristics, and prognosis of critically ill COVID 19 patients: a single-center experience through 4 successive waves

ObjectiveThe aim of this study was to describe the characteristics of patients admitted to the intensive care unit with severe pneumonia due to SARS-CoV-2, comparing them according to successive waves, and to identify prognostic factors for morbidity and mortality.Materials and methodsThis single-center retrospective observational descriptive study was conducted from March 10, 2020, to October 17, 2021. All adult patients admitted with SARS-CoV-2 pneumonia presenting acute respiratory failure were included. COVID 19 diagnosis was confirmed by RT-PCR testing of respiratory specimens. The primary endpoint was ICU mortality. Secondary endpoints were the occurrence of ventilator-associated pneumonia (VAP) or bronchopulmonary aspergillosis.ResultsOver the study period, 437 patients were included of whom 282 (65%) patients were ventilated for 9 [5;20] days. Among the studied population, 38% were treated for one or more episodes of VAP, and 22 (5%) for bronchopulmonary aspergillosis. ICU mortality was 26% in the first wave, then fell and stabilized at around 10% in subsequent waves (p = 0.02). Increased age, Charlson index, SOFA score and lactatemia on admission were predictive of mortality. Survival at 90 days was 85% (95% CI 82–88) and was unaffected by the presence of VAP. However, the occurrence of bronchopulmonary aspergillosis increased mortality to 36%.ConclusionIn this study, we observed mortality in the lower range of those previously reported. Risk factors for mortality mainly included age and previous comorbidities. The prognosis of these critically ill Covid 19 patients improved over the four waves, underlining the likely beneficial effect of vaccination and dexamethasone.