Critical Care Interventions Research Articles

Endovascular Therapy in Pediatric Stroke: Utilization, Patient Characteristics, and Outcomes

Background and PurposeDespite strong evidence for endovascular therapy in adults with acute arterial ischemic stroke, limited data exist in children. We aimed to describe endovascular therapy utilization and explore outcomes in a national sample of pediatric arterial ischemic stroke. MethodsWe queried the 2012 Kids' Inpatient Database for children aged greater than 28 days to 20 years with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for arterial ischemic stroke and evaluated groups based on the procedure code for endovascular therapy. Poor outcome was defined as need for tracheostomy or gastrostomy, discharge to rehabilitation facility, or death. Logistic regression evaluated the association between endovascular therapy and poor outcome, adjusted for age, disease severity (hemiplegia, critical care interventions, neurosurgical interventions), and comorbidities. ResultsWe identified 3184 pediatric discharges with a diagnosis code for arterial ischemic stroke. Thirty-eight (1%) had an endovascular therapy procedure code. Endovascular therapy patients were older (10.2 versus 4.5 years, P < 0.001) and more likely to have hemiplegia/paresis (relative risk [RR] 3.8, 95% confidence interval [CI] 2.0-7.4), aphasia (RR 5.3, 95% CI 2.8-10.1), and facial droop (RR 4.0, 95% CI 1.9-8.7). Endovascular therapy was not associated with critical care and neurosurgical interventions or intracranial hemorrhage. Length of hospitalization, mortality, and discharge disposition were similar between groups. In a multivariable model, endovascular therapy was not associated with poor outcome (adjusted odds ratio 1.7, 95%, CI 0.7-4.1). ConclusionsIn a national sample of children with a diagnosis of arterial ischemic stroke, endovascular therapy was infrequently utilized. Patients with a procedure code for endovascular therapy had significant stroke-related deficits, but outcomes were similar to those in children who did not receive endovascular therapy. Our data, in conjunction with evidence of benefit in adults, support consideration of endovascular therapy for select children with acute stroke.

Pediatric asthma severity score is associated with critical care interventions.

AIMTo determine if a standardized asthma severity scoring system (PASS) was associated with the time spent on continuous albuterol and length of stay in the pediatric intensive care unit (PICU).METHODSThis is a single center, retrospective chart review study at a major children’s hospital in an urban location. To qualify for this study, participants must have been admitted to the PICU with a diagnosis of status asthmaticus. There were a total of 188 participants between the ages of two and nineteen, excluding patients receiving antibiotics for pneumonia. PASS was calculated upon PICU admission. Subjects were put into one of three categories based on PASS: ≤ 7 (mild), 8-11 (moderate), and ≥ 12 (severe). The groups were compared based on different variables, including length of continuous albuterol and PICU stay.RESULTSThe age distribution across all groups was similar. The median length of continuous albuterol was longest in the severe group with a duration of 21.5 h (11.5-27.5), compared to 15 (7.75-23.75) and 10 (5-15) in the moderate and mild groups, respectively (P = 0.001). The length of stay was longest in the severe group, with a stay of 35.6 h (22-49) compared to 26.5 (17-30) and 17.6 (12-29) in the moderate and mild groups, respectively (P = 0.001).CONCLUSIONA higher PASS is associated with a longer time on continuous albuterol, an increased likelihood to require noninvasive ventilation, and a longer stay in the ICU. This may help safely distribute asthmatics to lower and higher levels of care in the future.

Selective Necrosectomy for Infected Pancreatic Necrosis

Background: Until recently, a diagnosis of infected pancreatic necrosis (IPN) warranted necrosectomy, which was associated with high morbidity and mortality rates greater than 20%. Preoperative percutaneous drainage delayed the need for necrosectomy with improved outcomes. Methods: In 2008, this institution changed its approach to the management of such cases opting instead for percutaneous drainage with selective deferred necrosectomy. A total of 38 consecutive patients with IPN from January 2008 to December 2014 were included. Results: All 38 underwent percutaneous radiological drainage, and selective necrosectomy was performed on 15 where the infected necrosis did not completely resolve. Twenty-three patients did not require surgery and were managed with pancreatic drain insertion, optimal nutritional support and critical care interventions. Median peak Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores were 10 (range 0-18) and 3 (range 0-10) prior to radiological intervention. Overall mortality was 5% (n = 2). Conclusion: This study demonstrates that radiological-guided drainage of infected pancreatic collections can, in most cases, prove curative and, if not, facilitates delayed surgical intervention with improved outcomes.

Prehospital critical care for out-of-hospital cardiac arrest: An observational study examining survival and a stakeholder-focused cost analysis.

BackgroundSurvival rates from out-of-hospital cardiac arrest (OHCA) remain low, despite remarkable efforts to improve care. A number of ambulance services in the United Kingdom (UK) have developed prehospital critical care teams (CCTs) which attend critically ill patients, including OHCA. However, current scientific evidence describing CCTs attending OHCA is sparse and research to date has not demonstrated clear benefits from this model of care.MethodsThis prospective, observational study will describe the effect of CCTs on survival from OHCA, when compared to advanced-life-support (ALS), the current standard of prehospital care in the UK. In addition, we will describe the association between individual critical care interventions and survival, and also the costs of CCTs for OHCA.To examine the effect of CCTs on survival from OHCA, we will use routine Utstein variables data already collected in a number of UK ambulance trusts. We will use propensity score matching to adjust for imbalances between the CCT and ALS groups. The primary outcome will be survival to hospital discharge, with the secondary outcome of survival to hospital admission.We will record the critical care interventions delivered during CCT attendance at OHCA. We will describe frequencies and aim to use multiple logistic regression to examine possible associations with survival.Finally, we will undertake a stakeholder-focused cost analysis of CCTs for OHCA. This will utilise a previously published Emergency Medical Services (EMS) cost analysis toolkit and will take into account the costs incurred from use of a helicopter and the proportion of these costs currently covered by charities in the UK.DiscussionPrehospital critical care for OHCA is not universally available in many EMS. In the UK, it is variable and largely funded through public donations to charities. If this study demonstrates benefit from CCTs at an acceptable cost to the public or EMS commissioners, it will provide a rationale to increase funding and service provision. If no clinical benefit is found, the public and charities providing these services can consider concentrating their efforts on other areas of prehospital care.Trial registrationISRCTN registry ID ISRCTN18375201.

Functional Status Scale in Children With Traumatic Brain Injury: A Prospective Cohort Study.

In children with traumatic brain injury, 1) to describe the hospital discharge functional outcome and change from baseline function using the Functional Status Scale and 2) to determine any associations between discharge Functional Status Scale and age, injury mechanism, neurologic examination, imaging, and other predictors of outcome. Prospective observational cohort study, May 2013 to November 2015. Two U.S. children's hospitals designated as American College of Surgeons level 1 pediatric trauma centers. Children less than 18 years old admitted to an ICU with acute traumatic brain injury and either a surgical or critical care intervention within the first 24 hours or in-hospital mortality. None. The primary outcome was hospital discharge Functional Status Scale. Most, 133 of 196 (68%), had severe traumatic brain injury (admission Glasgow Coma Scale, 3-8). Overall hospital mortality was 14%; 20% among those with severe traumatic brain injury. Hospital discharge Functional Status Scale had an inverse relationship with Glasgow Coma Scale: for each increase in admission Glasgow Coma Scale by 1, the discharge Functional Status Scale decreased by 0.5 (95% CI, 0.7-0.3). Baseline Functional Status Scale was collected at one site (n = 75). At that site, nearly all (61/62) of the survivors had normal or near-normal (≤ 7) preinjury Functional Status Scale. More than one-third, 23 of 62 (37%), of survivors had new morbidity at hospital discharge (increase in Functional Status Scale, ≥ 3). Among children with severe traumatic brain injury who had baseline Functional Status Scale collected, 21 of 41 survivors (51%) had new morbidity at hospital discharge. The mean change in Functional Status Scale from baseline to hospital discharge was 3.9 ± 4.9 overall and 5.2 ± 5.4 in children with severe traumatic brain injury. More than one-third of survivors, and approximately half of survivors with severe traumatic brain injury, will have new morbidity. Hospital discharge Functional Status Scale, change from baseline Functional Status Scale, and new morbidity acquisition can be used as outcome measures for hospital-based care process improvement initiatives and interventional studies of children with traumatic brain injury.

Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage: Identifying Low-Risk Patients Who May Not Benefit From ICU Admission.

Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary. To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI). We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI. Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6%; 95% confidence interval, 82.2%-99.9%) from the low-risk group, with a negative likelihood ratio of 0.056 (95% confidence interval, -0.053-0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55% of the sample). A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.

Utility of clinical decision rule for intensive care unit admission in patients with traumatic intracranial hemorrhage

BackgroundRecent literature suggests the majority of traumatic intracranial hemorrhage does not require intervention. One recently described clinical decision rule was sensitive in identifying patients requiring critical care interventions in an urban setting. We sought to validate its effectiveness in our predominately rural setting. MethodsA retrospective study was conducted of adult patients with traumatic intracranial hemorrhage. The rule, based on age, initial Glasgow coma scale score, and presence of a non-isolated head injury, was applied to externally validate the previously reported findings. ResultsIn our population, the rule displayed a sensitivity of 0.923, specificity of 0.251, positive predictive value of 0.393, and negative predictive value of 0.862. The area under curve was 0.587. While our population has a similar adjusted head injury severity score as that from which the rule was developed, significant differences in age and intracranial hemorrhage pattern were noted. ConclusionsThe rule displayed decreased performance in our population, most likely secondary to differences in age and intracranial hemorrhage patterns. Prospective evaluation and cost-savings analysis are appropriate subsequent steps for the rule.

PROTECTED-UK - Clinical pharmacist interventions in the UK critical care unit: exploration of relationship between intervention, service characteristics and experience level.

Clinical pharmacist (CP) interventions from the PROTECTED-UK cohort, a multi-site critical care interventions study, were further analysed to assess effects of: time on critical care, number of interventions, CP expertise and days of week, on impact of intervention and ultimately contribution to patient care. Intervention data were collected from 21 adult critical care units over 14 days. Interventions could be error, optimisation or consults, and were blind-coded to ensure consistency, prior to bivariate analysis. Pharmacy service demographics were further collated by investigator survey. Of the 20 758 prescriptions reviewed, 3375 interventions were made (intervention rate 16.1%). CPs spent 3.5 h per day (mean, ±SD 1.7) on direct patient care, reviewed 10.3 patients per day (±SD 4.2) and required 22.5 min (±SD 9.5) per review. Intervention rate had a moderate inverse correlation with the time the pharmacist spent on critical care (P = 0.05; r = 0.4). Optimisation rate had a strong inverse association with total number of prescriptions reviewed per day (P = 0.001; r = 0.7). A consultant CP had a moderate inverse correlation with number of errors identified (P = 0.008; r = 0.6). No correlation existed between the presence of electronic prescribing in critical care and any intervention rate. Few centres provided weekend services, although the intervention rate was significantly higher on weekends than weekdays. A CP is essential for safe and optimised patient medication therapy; an extended and developed pharmacy service is expected to reduce errors. CP services should be adequately staffed to enable adequate time for prescription review and maximal therapy optimisation.

Does the Presence of Multiple Respiratory Pathogens Indicate more Severe Illness in Hospitalized Children?

Background: There is new information regarding respiratory infection etiologies in Pediatrics. With the ability to test for 20 pathogens with a single nasal swab, we aimed to: 1. Study the relevance of respiratory pathogen testing in the con-text of hospitalized children and the incidence of multiple pathogens or "co-infection." 2. Determine whether patients with multiple pathogens have a longer length of stay (LOS) than those children with a single pathogen. 3. Determine whether children with multiple pathogens have more severe illness—as indicated by oxygen use, antibiotic use, or requirement of critical care—compared to those chil-dren with one pathogen identified. Methods: Electronic medical records of patients who had respiratory pathogen panel (RPP) polymerase chain reaction (PCR) testing during the winter of 2011-2012 at a tertiary care chil-dren’s hospital were reviewed. RPP results, LOS, oxygen use, antibiotic use, and critical care interven-tions were noted. Data were analyzed with Pearson chi-square and Cox proportional hazard regression. Results: 93 RPPs (83%) tested positive for a single pathogen, and 19 RPPs (17%) were positive for multiple pathogens. Patients with co-infections had more severe disease as defined by the requirement of intensive care (p=0.02, OR 3.51, 1.2-9.8). There was no significant difference in oxygen use or antibiotic use between patients with one or more than one pathogen. The co-infection group was hospitalized for a median of 67 hours versus 41 hours for the single pathogen group (p= 0.01). This increased hospital LOS for the co-infection group was also seen in Cox regression analysis (p=0.007). Conclusions: Hospitalized children with multiple pathogens on RPP testing have statistically longer LOS and more severe illness. Keywords: Bronchiolitis, respiratory pathogen panel, co-infection, antibiotic, polymerase chain reaction.

Aligning critical care interventions with patient goals: A modified Delphi study

ObjectiveTo develop a list of non-emergent, potentially harmful interventions commonly performed in ICUs that require a clear understanding of patients' treatment goals. BackgroundA 2016 policy statement from the American Thoracic Society and American College of Critical Care Medicine calls on intensivists to engage in shared decision-making when “making major treatment decisions that may be affected by personal values, goals, and preferences.” MethodsA three-round modified Delphi consensus process was conducted via a panel of 6 critical care physicians, 6 ICU nurses, 6 former ICU patients, and 6 family members from 6 academic and community-based medical institutions in the U.S. mid-Atlantic region. ResultsRecommendations about 8 interventions achieved consensus among respondents. ConclusionsClinical and patient/family participants in a modified Delphi consensus process were able to identify preference-sensitive decisions that should trigger clinicians to clarify patient goals and consider initiating shared decision-making.

The interplay between microbiota and inflammation: lessons from peritonitis and sepsis.

Mammals harbor a complex gut-associated microbiota, comprising bacteria that provide immunological, metabolic and neurological benefits to the host, and contribute to their well-being. However, dysregulation of the microbiota composition, known as dysbiosis, along with the associated mucosal immune response have a key role in the pathogenesis of many inflammatory diseases, including inflammatory bowel diseases (IBDs), type 1 and type 2 diabetes, asthma, multiple sclerosis, among others. In addition, outside the gut lumen, bacteria from microbiota are the causative agent of peritoneal inflammation, abdominal sepsis and systemic sepsis. Critical care interventions during sepsis by antibiotics induce dysbiosis and present acute and long-term poor prognosis. In this review, we discuss immunomodulatory effects of the microbial molecules and products, highlighting the role of Bacteroides fragilis, a human commensal with ambiguous interactions with the host. Moreover, we also address the impact of antibiotic treatment in sepsis outcome and discuss new insights for microbiota modulation.

Incidence, Risk Factors and Outcomes of New Onset Supraventricular Arrhythmias in African American Patients with Severe Sepsis.

New onset supraventricular arrhythmias (SVA) are commonly reported in mixed intensive care settings. We sought to determine the incidence, risk factors and outcomes of new onset SVA in African American (AA) patients with severe sepsis admitted to medical intensive care unit (MICU). Patients admitted to MICU between January 2012 through December 2012 were studied. Patients with a previous history of arrhythmia or with new onset of ventricular arrhythmia were excluded. Data on risk factors, critical care interventions and outcomes were obtained. One hundred and thirty-one patients were identified. New onset SVA occurred in 34 (26%) patients. Of those 34, 20 (59%) had atrial fibrillation (AF), 6 (18%) had atrial flutter and 8 (24%) had other forms of SVA. Compared with patients without SVA, patients with new onset SVA were older (69 ± 12 yrs vs 59 ± 13 yrs, P=.003), had congestive heart failure (47% vs 24%, P=.015) and dyslipidemia (41% vs 15%, P=.002). Additionally, they had a higher mean mortality prediction model (MPM II) score (65 ± 25 vs 49 ± 26, P=.001) and an increased incidence of respiratory failure (85% vs 55%, P=.001). Hospital mortality in patients with new onset SVA was 18 (53%) vs 30 (31%); P=.024; however, in a multivariate analysis, new onset SVA was associated with non-significantly increased odds (OR 2.58, 95% CI 0.86-8.05) for in-hospital mortality. New onset SVA was prevalent in AA patients with severe sepsis and occurred more frequently with advanced age, increased severity of illness, congestive heart failure, and acute respiratory failure; it was associated with higher unadjusted in hospital mortality. However, after multiple adjustments, new onset SVA did not remain an independent predictor of mortality.

Invasive Mechanical Ventilation and Mortality in Pediatric Hematopoietic Stem Cell Transplantation

To establish the current respiratory practice patterns in pediatric hematopoietic stem cell transplant patients and investigate their associations with mortality across multiple centers. Retrospective cohort between 2009 and 2014. Twelve children's hospitals in the United States. Two hundred twenty-two pediatric allogeneic hematopoietic stem cell transplant recipients with acute respiratory failure using invasive mechanical ventilation. None. PICU mortality of our cohort was 60.4%. Mortality at 180 days post PICU discharge was 74%. Length of PICU stay prior to initiation of invasive mechanical ventilation was significantly lower in survivors, and the odds of mortality increased for longer length of PICU stay prior to intubation. A total of 91 patients (41%) received noninvasive ventilation at some point during their PICU stay prior to intubation. Noninvasive ventilation use preintubation was associated with increased mortality (odds ratio, 2.1; 95% CI, 1.2-3.6; p = 0.010). Patients ventilated longer than 15 days had higher odds of death (odds ratio, 2.4; 95% CI, 1.3-4.2; p = 0.004). Almost 40% of patients (n = 85) were placed on high-frequency oscillatory ventilation with a mortality of 76.5% (odds ratio, 3.3; 95% CI, 1.7-6.5; p = 0.0004). Of the 20 patients who survived high-frequency oscillatory ventilation, 18 were placed on high-frequency oscillatory ventilation no later than the third day of invasive mechanical ventilation. In this subset of 85 patients, transition to high-frequency oscillatory ventilation within 2 days of the start of invasive mechanical ventilation resulted in a 76% decrease in the odds of death compared with those who transitioned to high-frequency oscillatory ventilation later in the invasive mechanical ventilation course. This study suggests that perhaps earlier more aggressive critical care interventions in the pediatric hematopoietic stem cell transplant patient with respiratory failure requiring invasive mechanical ventilation may offer an opportunity to improve outcomes.

Comparing the surgical timelines of military and civilians traumatic lower limb amputations.

The care and challenges of injured service have been well documented in the literature from a variety of specialities.The aim of this study was to analyse the surgical timelines of military and civilian traumatic amputees and compare the surgical and resuscitative interventions.A retrospective review of patient notes was undertaken. Military patients were identified from the Joint Theatre Trauma Registry (JTTR) in 2009. Civilian patients were identified using the hospital informatics database. Patient demographics, treatment timelines as well as surgical and critical care interventions were reviewed.In total 71 military patients sustained traumatic amputations within this time period. This represented 11% of the total injury demographic in 2009. Excluding upper limb amputees 46 patients sustained lower extremity amputations. These were investigated further. In total 21 civilian patients were identified in a 7-year period.Analysis revealed there was a statistically significant difference between patient age, ITU length of stay, blood products used and number of surgical procedures between military and civilian traumatic amputees. This study identified that military patients were treated for longer in critical care and required more surgical interventions for their amputations.Despite this, their time to stump closure and length of stay were not statistically different compared to civilian patients. Such observations reflect the importance of an Orthoplastic approach, as well as daily surgical theatre co-ordination and weekly multi-disciplinary meetings in providing optimal care for these complex patients. This study reports the epidemiological observed differences between two lower limb trauma groups.

Infective endocarditis prophylaxis in patients undergoing oral surgery

Infective endocarditis (IE), an infection of the endocardium that usually involves the valves and adjacent structures, may be caused by a wide variety of bacteria and fungi that entered the bloodstream and settled in the heart lining, a heart valve or a blood vessel. The IE is uncommon, but people with some heart conditions have a greater risk of developing it. Despite advances in medical, surgical, and critical care interventions, the IE remains a disease that is associated with considerable morbidity and mortality. Hence, in order to minimize the risk of adverse outcome and achieve a yet better management of complications, it is crucial to increase the awareness of all the prophylactic measures of the IE. For the past 50 years, the guidelines for the IE prophylaxis have been under constant changes. The purpose of this paper is to review current dental and medical literature considering the IE prophylaxis, including the new and updated guidelines from the American Heart Association (AHA, 2007 and 2015), the National Institute for Health and Clinical Excellence (NICE, 2015), the European Society of Cardiology (ESC, 2009 and 2015) and the British Society for Antimicrobial Chemotherapy (BSAC, 2006).

Troponin elevation predicts critical care needs and in-hospital mortality after thrombolysis in white but not black stroke patients

IntroductionStroke patients undergoing intravenous thrombolysis (IVT) are at increased risk for critical care interventions and mortality. Cardiac troponin elevation is common in stroke patients; however, its prognostic significance is unclear. The present study evaluates troponin elevation as a predictor of critical care needs and mortality in post-IVT patients and describes racial differences in its predictive accuracy. MethodsLogistic regression and receiver operating characteristics (ROC) analysis were used to determine racial differences in the predictive accuracy of troponin elevation for critical care needs and mortality in post-IVT patients. ResultsTroponin elevation predicted critical care needs in white (odds ratio [OR] 29.40, 95% confidence interval [CI] 4.86-177.81) but not black patients (OR 0.50, 95% CI 0.14-1.78; P value for interaction < .001). Adding troponin elevation to a prediction model for critical care needs in whites improved the area under the curve from 0.670 to 0.844 (P = .006); however, addition of troponin elevation did not improve the model in blacks (area under the curve 0.843 vs 0.851, P = .54). Troponin elevation was associated with in-hospital mortality in whites (OR 21.94, 95% CI 3.51-137.11) but not blacks (OR 1.10, 95% CI 0.19-6.32, P value for interaction .022). ConclusionTroponin is a useful predictor of poor outcome in white but not black post-IVT stroke patients.

ICAT: a simple score predicting critical care needs after thrombolysis in stroke patients.

BackgroundPatients receiving intravenous thrombolysis (IVT) for acute ischemic stroke are at risk of developing complications, commonly necessitating admission to an intensive care unit (ICU). At present, most IVT is administered in the Emergency Department or in dedicated stroke units, but no evidence-based criteria exist that allow for early identification of patients at increased risk of developing ICU needs. The present study describes a novel prediction score aiming to identify a subpopulation of post-IVT patients at high risk for critical care interventions.MethodsWe retrospectively analyzed data from 301 patients undergoing IVT at our institutions during a 5-year period. Two hundred and ninety patients met inclusion criteria. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of critical care needs based on strength of association.ResultsSeventy-two patients (24.8 %) required critical care interventions. Black race (odds ratio [OR] 3.81, p =0.006), male sex (OR 3.79, p =0.008), systolic blood pressure (SBP; OR 1.45 per 10 mm Hg increase in SBP, p <0.001), and NIH stroke scale (NIHSS; OR 1.09 per 1 point increase in NIHSS, p =0.071) were independent predictors of critical care needs. The optimal model for score development, predicting critical care needs, achieved an AUC of 0.782 in the validation group. The score was named the ICAT (Intensive Care After Thrombolysis) score, assigning the following points: black race (1 point), male sex (1 point), SBP (2 points if 160–200 mm Hg; 4 points if >200 mm Hg), and NIHSS (1 point if 7–12; 2 points if >12). Each 1-point increase in the score was associated with 2.22-fold increased odds for critical care needs (95 % CI 1.78–2.76, p <0.001). A score ≥2 was associated with over 13 times higher odds of critical care needs compared to a score <2 (OR 13.60, 95 % CI 3.23–57.19), predicting critical care with 97.2 % sensitivity and 28.0 % specificity.ConclusionThe ICAT score, combining information about race, sex, SBP, and NIHSS, predicts critical care needs in post-IVT patients and may be helpful when triaging post-IVT patients to the appropriate monitoring environment.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1195-7) contains supplementary material, which is available to authorized users.

Which patients need critical care intervention after total joint arthroplasty? : a prospective study of factors associated with the need for intensive care following surgery.

Older patients with multiple medical co-morbidities are increasingly being offered and undergoing total joint arthroplasty (TJA). These patients are more likely to require intensive care support, following surgery. We prospectively evaluated the need for intensive care admission and intervention in a consecutive series of 738 patients undergoing elective hip and knee arthroplasty procedures. The mean age was 60.6 years (18 to 91; 440 women, 298 men. Risk factors, correlating with the need for critical care intervention, according to published guidelines, were analysed to identify high-risk patients who would benefit from post-operative critical care monitoring. A total of 50 patients (6.7%) in our series required critical care level interventions during their hospital stay. Six independent multivariate clinical predictors were identified (p < 0.001) including a history of congestive heart failure (odds ratio (OR) 24.26, 95% confidence interval (CI) 9.51 to 61.91), estimated blood loss > 1000 mL (OR 17.36, 95% CI 5.36 to 56.19), chronic obstructive pulmonary disease (13.90, 95% CI 4.78 to 40.36), intra-operative use of vasopressors (OR 8.10, 95% CI 3.23 to 20.27), revision hip arthroplasty (OR 2.71, 95% CI 1.04 to 7.04) and body mass index > 35 kg/m(2) (OR 2.70, 95% CI 123 to 5.94). The model was then validated against an independent, previously published data set of 1594 consecutive patients. The use of this risk stratification model can be helpful in predicting which high-risk patients would benefit from a higher level of monitoring and care after elective TJA and aid hospitals in allocating precious critical care resources.

Implementation of critical care staff based rapid response team. effect of rapid response system to the unpredicted death

Our hospital is a tertiary 1000-bed hospital. In 2011, rapid response system (RRS) was introduced in the hospital. Our rapid response team (RRT) includes critical care physicians, critical care nurses and physical therapists. Usually, team members are working at ICU. They also provides respiratory care or critical care interventions to the patients in the wards, after discharged from ICU. It is just like a Critical Care Outreach Team (CCOT), however, we call the system, Respiratory Support Team (RST) in our country. Once the RRS is activated, the team immediately responds to any type of call during 24 hours a day. The RRS is activated according to predefined criteria.

New Insights Into Multicenter PICU Mortality Among Pediatric Hematopoietic Stem Cell Transplant Patients.

Over 2,500 children undergo hematopoietic stem cell transplantation in the United States each year, and up to 35% require PICU support for life-threatening complications. PICU mortality has dropped from 85% to 44%, but interpretation is confounded by significant cohort heterogeneity. Reports conflict regarding outcomes for patients with different underlying hematopoietic stem cell transplantation indications, and the burden of infectious complications for these patients has not been evaluated. We aim to describe infections, critical care interventions, and mortality for pediatric hematopoietic stem cell transplantation patients requiring PICU admission. A retrospective multicenter cohort analysis. One hundred twelve centers in the Virtual PICU Systems database, January 1, 2009, to June 30, 2012. A total of 1,782 admissions for patients who are 21 years old or younger with prior hematopoietic stem cell transplantation. None. Pediatric Index of Mortality-2, Pediatric Risk of Mortality-3, transplant indication, infections, interventions, and mortality were recorded from admission through PICU death or discharge. Pediatric hematopoietic stem cell transplantation patients comprised 0.7% of all PICU admissions (1,782/246,346), which resulted in 16.2% mortality compared with 2.4% mortality for non-hematopoietic stem cell transplantation admissions (odds ratio, 7.8; 95% CI, 6.8-8.8; p < 0.001). Mortality for admissions with underlying hematologic malignancy (22.7%) was similar to that of admissions with primary immunodeficiency (19.4%; p = 0.41) but significantly greater than admissions with underlying nonmalignant non-primary immunodeficiency hematologic disease (15.4%; p = 0.020), metabolic disorder (8.1%; p < 0.001), or solid malignancy (5.7%; p < 0.001). Infection was documented in 45.7% of admissions with 22.2% mortality; viral and fungal mortality were 28.5% and 33.7%, respectively. Invasive positive pressure ventilation and renal replacement therapy were used in only 34.6% and 11.9% of admissions, with mortality of 42.5% and 51.9%, respectively. PICU mortality for pediatric hematopoietic stem cell transplantation patients may be as low as 16.2% but higher for those receiving intubation (42.5%) or replacement therapy (51.9%). Hematologic malignancy and primary immunodeficiency had greater risk for mortality than other transplant indications. Greater understanding of other risk factors affecting mortality and the need for critical care support is needed.