Intensive Care Unit Length Research Articles

The Predictive Value of Qanadli and Miller Index Scores in Patients with Intermediate-High–Risk and High-Risk Pulmonary Emboli Undergoing Aspiration Thrombectomy

PurposeTo evaluate the correlation between clot burden and pulmonary artery pressures in patients undergoing suction thromboembolectomy for high-risk and intermediate-high–risk pulmonary embolism with secondary outcomes of 30-day mortality and intensive care unit (ICU) length of stay. Materials and MethodsInstitutional review board (IRB) exemption was granted for this retrospective study. The charts of 120 consecutive patients who underwent mechanical thromboembolectomy using the Flowtriever system (Inari Medical, Irvine, California) between February 2020 and August 2022 were retrospectively reviewed, and the following data were collected: (a) preprocedural B-type natriuretic peptide and creatinine levels, (b) echocardiographic findings, (c) preprocedural and postprocedural pulmonary artery pressures, (d) ICU length of stay, and (e) 30-day mortality. Clot burden was scored using Qanadli and Miller indices and correlated with the clinical outcomes. ResultsOf the 120 patients who underwent thromboembolectomy, pulmonary artery pressures and diagnostic-quality angiograms were available in 109 patients. In the 109 patients with adequate data, Qanadli, preprocedural Miller, and postprocedural Miller scores correlated with pulmonary artery pressures. Neither was independently associated with ICU length of stay. Freedom from 30-day mortality was 91%, and embolism-specific mortality was 92%. All-risk and high-risk patients who survived demonstrated a significantly lower preprocedural and postprocedural Miller score, respectively. ConclusionsThrombus burden as measured by the Qanadli and Miller scores appeared to be correlated with pulmonary artery pressures. Furthermore, catheter-directed thromboembolectomy led to a reduction in Miller scores, which appeared to be correlated with a reduction in pulmonary pressures. In high-risk patients, a reduced postprocedural Miller score and pulmonary pressure demonstrated improved 30-day survival. Further investigation into the association between Miller scores and patient mortality is warranted to stratify patients who would benefit from emergency intervention.

Upper gastrointestinal bleeding on veno-arterial extracorporeal membrane oxygenation support

IntroductionPatients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support are at a high risk of hemorrhagic complications, including upper gastrointestinal bleeding (UGIB). The objective of this study was to evaluate the incidence and impact of this complication in V-A ECMO patients.Materials and methodsA retrospective single-center study (2013–2017) was conducted on V-A ECMO patients, excluding those who died within 24 h. All patients with suspected UGIB underwent esophagogastroduodenoscopy (EGD) and were analyzed and compared to the remainder of the cohort, from the initiation of ECMO until 5 days after explantation.ResultsA total of 150 V-A ECMO cases (65 after cardiac surgery and 85 due to medical etiology) were included. 90% of the patients received prophylactic proton pump inhibitor therapy and enteral nutrition. Thirty-one patients underwent EGD for suspected UGIB, with 16 confirmed cases of UGIB. The incidence was 10.7%, with a median occurrence at 10 [7–17] days. There were no significant differences in clinical or biological characteristics on the day of EGD. However, patients with UGIB had significant increases in packed red blood cells and fresh frozen plasma needs, mechanical ventilation duration and V-A ECMO duration, as well as in length of intensive care unit and hospital stays. There was no significant difference in mortality. The only independent risk factor of UGIB was a history of peptic ulcer (OR = 7.32; 95% CI [1.07–50.01], p = 0.042).ConclusionUGIB occurred in at least 1 out of 10 cases of V-A ECMO patients, with significant consequences on healthcare resources. Enteral nutrition and proton pump inhibitor prophylaxis did not appear to protect V-A ECMO patients. Further studies should assess their real benefits in these patients with high risk of hemorrhage.

Use of Corticosteroids on Prophylaxis of New-Onset Atrial Fibrillation after Cardiac Surgery

Abstract Background Most cardiac operations are performed under cardiopulmonary bypass(CPB); however, it is well known that cardiopulmonary bypass often causes systemic inflammatory response syndrome (SIRS). Cardiac tissue inflammation induced by the CPB and surgical trauma has been previously hypothesized to cause POAF. The relationship between inflammation and atrial fibrillation after cardiac surgery is further strengthened by studies that showed that corticosteroid (CS) prophylaxis can reduce the occurrence of atrial fibrillation after cardiac surgery. Aim of the Work to determine the efficacy of corticosteroids in prophylaxis of POAF and shorten length of intensive care unit (ICU) and hospital stay. Patients and Methods This is randomized controlled clinical trial on 84 patients who underwent their first elective cardiac surgery under cardiopulmonary bypass in Ain Shams University Hospitals. Patients were randomized into two equal groups (n = 42 each) as the control group who underwent a standard cardiopulmonary bypass without any additional medication which was performed under the supervision of a specialized elite and experts in their specialization, and the Methylprednisolone (MP) group who was given 1 g of methylprednisolone (divided into 250 mg every 6h once in the ICU), The primary outcome is the overall occurrence of postoperative AF during the first 72 hours after cardiac surgery. Secondary outcomes are the length of hospital stay, and intensive care unit (ICU) stay. Results This study revealed that using corticosteroids effective in reducing the incidence of POAF without increasing the incidence of postoperative complications and adverse effects due to corticosteroids therapy. This study showed decreased risk of developing AF in patients undergoing cardiac surgery. The incidence of POAF was found be significant lower in MP group 16.7% (7 patients developed AF) versus 35.7% in the control group (15 patients developed AF) (p 0.047). Conclusion Use of Corticosteroids is effective in prophylaxis of POAF in patients undergoing elective cardiac surgery in terms of reducing its incidence and decreasing the length of ICU and hospital stay.

Treatment of acute kidney injury with continuous renal replacement therapy and cytokine adsorber (CytoSorb®) in critically ill patients with COVID-19.

This retrospective study aimed to evaluate the 30 and 60-day survival of critically ill patients with COVID-19 and AKI. Inflammatory and biochemical biomarkers, length of intensive care unit (ICU) stay and mortality at Day 30 and Day 60 after ICU admission were analyzed. A total of 44 patients treated with continuous renal replacement therapy (CRRT) with cytokine adsorber (CA group) were compared to 58 patients treated with CRRT alone (non-CA group). Patients in CA group were younger, had better preserved kidney function prior to the beginning of CRRT and had higher levels of interleukin-6. There were no statistically significant differences in their comorbidities and in other measured biomarkers between the two groups. The number of patients who died 60 days after ICU admission was statistically significantly higher in non-CA group (p = 0.029). Treatment with CRRT and cytokine adsorber may have positively influenced 60-day survival in our COVID-19 ICU patients with AKI.

Preoperative Evidence-Based Practice for Prevention of Early Postoperative Infections in Patients Receiving a Liver Transplant.

BACKGROUND This study aimed to evaluate the effectiveness of implementing evidence-based preoperative nursing interventions in reducing postoperative infections and intensive care unit (ICU) length of stay among liver transplant recipients. MATERIAL AND METHODS A controlled study was conducted, comparing postoperative outcomes between an intervention group receiving standardized, evidence-based preoperative care and a control group receiving routine preoperative care. Patients undergoing elective liver transplantation from September 2020 to March 2021 were included and assigned to either the intervention or control group. The intervention group received preoperative interventions based on best available evidence, while the control group received standard preoperative care. The primary outcomes measured were postoperative infection rates and length of ICU stay. RESULTS In the control group the overall Intensive Care Unit (ICU) length of stay was 3 days and the infection rate was 33.30%, while in the intervention group it was 3 days and 13.80% (P<0.05). There was no significant difference in the length of ICU stay between the control and the intervention groups (P>0.05). There was a significant improvement in the awareness, acceptance, and compliance of doctors and nurses. CONCLUSIONS Using the best evidence-based intervention for preoperative nursing of liver transplantation patients can standardize preoperative nursing behavior. Although we did not find significant differences in outcomes before and after the intervention, it is necessary to prevent postoperative infection and improve nursing compliance.

The predictors of fungal infections after liver transplantation and the influence of fungal infections on outcomes

The primary objective of this study was to assess the incidence, timing, risk factors of fungal infections (FIs) within 3 months after liver transplantation (LT). The secondary objective was to evaluate the impact of FIs on outcomes. Four hundred and ten patients undergoing LT from January 2015 until January 2023 in a tertiary university hospital were included in the present retrospective cohort study to investigate the risk factors of FIs and to assess the impacts of FIs on the prognosis of LT recipients using logistic regression. The incidence of FIs was 12.4% (51/410), and median time from LT to the onset of FIs was 3 days. By univariate analysis, advanced recipient age, prolonged hospital stay prior to LT, high Model for End Stage Liver Disease (MELD) score, use of broad-spectrum antibiotics, and elevated white blood cell (WBC) count, increased operating time, massive blood loss and red blood cell transfusion, elevated alanine aminotransferase on day 1 and creatinine on day 3 after LT, prolonged duration of urethral catheter, prophylactic antifungal therapy, the need for mechanical ventilation and renal replacement therapy were identified as factors of increased post-LT FIs risk. Multivariate logistic regression analysis identified that recipient age ≥ 55 years[OR = 2.669, 95%CI: 1.292–5.513, P = 0.008], MELD score at LT ≥ 22[OR = 2.747, 95%CI: 1.274–5.922, P = 0.010], pre-LT WBC count ≥ 10 × 109/L[OR = 2.522, 95%CI: 1.117–5.692, P = 0.026], intraoperative blood loss ≥ 3000 ml [OR = 2.691, 95%CI: 1.262–5.738, P = 0.010], post-LT duration of urethral catheter > 4 d [OR = 3.202, 95%CI: 1.553–6.602, P = 0.002], and post-LT renal replacement therapy [OR = 5.768, 95%CI: 1.822–18.263, P = 0.003] were independently associated with the development of post-LT FIs. Post-LT prophylactic antifungal therapy ≥ 3 days was associated with a lower risk of the development of FIs [OR = 0.157, 95%CI: 0.073–0.340, P < 0.001]. As for clinical outcomes, FIs had a negative impact on intensive care unit (ICU) length of stay ≥ 7 days than those without FIs [OR = 3.027, 95% CI: 1.558–5.878, P = 0.001] but had no impact on hospital length of stay and 1-month all-cause mortality after LT. FIs are frequent complications after LT and the interval between the onset of FIs and LT was short. Risk factors for post-LT FIs included high MELD score at LT, advanced recipient age, pre-LT WBC count, massive intraoperative blood loss, prolonged post-LT duration of urethral catheter, and the need for post-LT renal replacement therapy. However, post-LT prophylactic antifungal therapy was independently associated with the reduction in the risk of FIs. FIs had a significant negative impact on ICU length of stay.

Ultrasound Diaphragmatic Assessment as a Predictor of Successful Non-Invasive Mechanical Ventilation in Patients with Acute Exacerbation COPD: an Observational Study

Abstract Background Non-invasive ventilation (NIV) is successful as first-line treatment for patients admitted to hospital with hypercapnic respiratory failure due to AECOPD. Significant diaphragmatic muscle dysfunction (DD) exits in different disease-related and physiological conditions, including COPD. Ultrasonography is considered as a non- invasive and bedside method and commonly applied in intensive care unit (ICU) to assess diaphragmatic function. Objective To demonstrate the value of diaphragmatic ultrasound assessment for patients with AECOPD undergoing NIMV. Patients and Methods A population of 24 consecutive patients with AECOPD admitted to Ain Shams University Hospitals’ Intensive Care units (ICU) were enrolled. Change in diaphragmatic thickness fraction (ΔDTF) &amp;lt; 20% and diaphragm excursion&amp;lt; 10 mm during tidal volume was the predefined cut-off for identifying DD. Correlations between ΔDTF &amp;lt; 20%, diaphragm excursion&amp;lt; 10 mm and NIV failure and other clinical outcomes were investigated. Results 24 cases with AECOPD, 33.3% of them (8 cases) had diaphragm dysfunction (DD+) but after NICPAP 2 cases improved and only 6 cases remain with DD and 16 Patients without DD (DD−). DD+ patients had a higher risk for NIV failure than DD−patients (p &amp;lt; 0.011), and this finding was significantly associated with higher in-hospital, and 30-day mortality rates; longer mechanical ventilation duration; higher tracheostomy rate; and longer ICU stay. Conclusion AECOPD patients with diaphragmatic dysfunction as diagnosed by US showed higher incidence of NIMV failure, longer MV, ICU length of stay, In- hospital mortality, ICU and MV duration were significantly longer in group with DD. Insignificant difference was found considering mortality after 30 days in patients with or without diaphragm dysfunction.

Pulmonary artery catheter use and in-hospital outcomes in cardiac surgery: a systematic review and meta-analysis.

To determine the association of intraoperative pulmonary artery catheter (PAC) use with in-hospital outcomes in cardiac surgical patients. MEDLINE, Embase, and Cochrane Library (Wiley) databases were screened for studies that compared cardiac surgical patients receiving intraoperative PAC with controls and reporting in-hospital mortality. Secondary outcomes included intensive care unit length of stay, cost of hospitalization, fluid volume administered, intubation time, inotropes use, acute kidney injury (AKI), stroke, myocardial infarction (MI), and infections. Seven studies (25853 patients, 88.6% undergoing coronary artery bypass graft surgery) were included. In-hospital mortality was significantly increased with PAC use [odds ratio (OR) 1.57; 95% confidence interval (CI) 1.12-2.20, P = 0.04]; PAC use was also associated with greater intraoperative inotrope use (OR 2.61; 95% CI 1.54-4.41) and costs [standardized mean difference (SMD) = 0.20; 95% CI 0.16-0.23], longer intensive care unit stay (SMD = 0.29; 95% CI 0.25-0.33), and longer intubation time (SMD = 0.44; 95% CI 0.12-0.76). PAC use is associated with significantly increased odds of in-hospital mortality, but the amount and quality of the available evidence is limited. Prospective randomized trials testing the effect of PAC on the outcomes of cardiac surgical patients are urgently needed.

Low incidence of deep vein thrombosis in critically ill medical patients in Thais: a prospective study

BackgroundCritically ill medical patients face a heightened risk of developing venous thromboembolism. In Thailand, routine thromboprophylaxis is not employed. The incidence of deep vein thrombosis (DVT) in the medical intensive care unit (ICU) has not been elucidated in the Thai population. ObjectivesThe aims were to evaluate the incidence of DVT and identify associated risk factors in critically ill medical patients. MethodsA single-center, prospective cohort study was conducted from 2019 to 2020. Consecutive patients underwent screening for proximal DVT by duplex ultrasound of both legs. ResultsA total of 200 patients were enrolled, with 115 being male (57%). The mean (SD) age was 66.5 (16.4) years. The mean (SD) Acute Physiology and Chronic Health Evaluation II score was 27 (8). The cumulative incidence of DVT over 5 days was 7% (95% CI, 3.4%-10.6%). No clinically or radiologically diagnosed pulmonary embolism occurred in patients with DVT. No independent risk factor associated with DVT was identified. Hospital mortality in those with and those without DVT was 42.9% and 32.3%, respectively. There was no significant difference in the length of ICU or hospital stay or inpatient mortality between those with and those without DVT. ConclusionWithout thromboprophylaxis, the incidence of DVT in the Thai population remains low. A strategy of screening ultrasound 5 to 7 days after admission to the ICU may be a suitable alternative to anticoagulant prophylaxis in critically ill Thai patients without symptoms of venous thromboembolism.

Predictive value of leukocyte derived markers for postoperative delirium after cardiac valve surgery

To explore the predictive value of leukocyte derived markers for postoperative delirium (POD) in patients undergoing cardiac valve surgery. A prospective cohort study was conducted. The patients who underwent cardiac valve surgery admitted to Beijing Anzhen Hospital of Capital Medical University from October 2021 to March 2023 were enrolled. The demographic, baseline and perioperative data were collected, and the neutrophil to lymphocyte ratio (NLR) and platelet to white blood cell ratio (PWR) were calculated before operation and within 24 hours after operation. Delirium assessment was conducted twice a day for patients within 1-5 days after surgery or discharged within 5 days. According to the evaluation results, the patients were divided into delirium group and non-delirium group. The clinical indexes between the two groups were compared. Multivariate Logistic regression analysis was used to screen the independent risk factors of POD, and the POD predictive model was constructed. The predictive value of POD predictive model was evaluated by receiver operator characteristic curve (ROC curve). A total of 235 patients were enrolled in the analysis, of which 83 patients had POD (35.32%) and 152 patients did not have POD (64.68%). Compared with the non-delirious group, the patients in the delirious group had higher Charlson comorbidity index (CCI) score and lower mini-mental state examination (MMSE) score. In terms of perioperative data, compared with the non-delirium group, the patients in the delirium group had longer operative time, duration of cardiopulmonary bypass, length of intensive care unit (ICU) stay, duration of mechanical ventilation, and postoperative hospital stay, higher incidence of perioperative atrial fibrillation, and lower discharge life score. In terms of leukocyte derived markers, NLR within 24 hours after surgery in both groups were significantly higher than those before surgery, and PWR were significantly lower than those before surgery. The NLR within 24 hours after surgery, PWR difference and NLR difference in the delirium group were significantly higher than those in the non-delirium group. Multivariate Logistic regression analysis showed that CCI score [odds ratio (OR) = 1.394, 95% confidence interval (95%CI) was 1.038-1.872, P = 0.027], perioperative atrial fibrillation (OR = 3.697, 95%CI was 1.711-7.990, P < 0.001), duration of cardiopulmonary bypass (OR = 1.008, 95%CI was 1.002-1.015, P = 0.016), length of ICU stay (OR = 1.006, 95%CI was 1.002-1.010, P = 0.002), NLR difference (OR = 1.029, 95%CI was 1.009-1.050, P = 0.005) and PWR difference (OR = 1.044, 95%CI was 1.009-1.080, P = 0.013) were independently correlated with POD. POD predictive model was constructed by multivariate Logistic regression analysis result: POD predictive model index = -4.970+0.336×CCI score+1.317×perioperative atrial fibrillation+0.009×duration of cardiopulmonary bypass+0.006×length of ICU stay+0.030×NLR difference+0.044×PWR difference. ROC curve analysis showed that the area under the ROC curve (AUC) of NLR difference for predicting POD was 0.659 (95%CI was 0.583-0.735), the optimal critical value was 16.62, the sensitivity was 60.2%, and the specificity was 70.4% (P < 0.05). The AUC of PWR difference for predicting POD was 0.608 (95%CI was 0.528-0.688), the optimal critical value was 25.68, the sensitivity was 51.8%, and the specificity was 75.7% (P < 0.05). The AUC of POD predictive model for predicting POD was 0.805 (95%CI was 0.745-0.865), the optimal critical value was 0.39, the sensitivity was 74.7%, and the specificity was 79.6% (P < 0.05). The differences of NLR and PWR are independently related to POD, which has potential value in predicting POD after cardiac valve surgery.

Sex-Based Differences in Clinical Characteristics of Patients with Acute Myocarditis: A Cohort Study

BackgroundThis study investigated sex differences in acute myocarditis patients during index hospitalization. MethodsWe included 365 patients with acute myocarditis, hospitalized with continuous monitoring at the intensive care unit from 2000-2023 into the Basel Myocarditis Cohort study. We compared sex differences in clinical presentation, the presenting electrocardiogram, prior medical history, inflammatory and cardiac biomarkers, cardiac imaging, arrhythmia occurrence, and short- to midterm outcomes. ResultsMean age was 41.3 years, and 26.3% were female. Compared with men, women were older (median 49.7 vs 38.3 years, P < .001) at the time of diagnosis and presented more frequently with dyspnea (41 vs 26%, P = .013) and a higher Killip class (P = .011). In the presenting electrocardiogram, men had a higher occurrence of diffuse ST-elevation (38 vs 9%, P < .001) and PQ-depression (31 vs 20%, P = .042), compared with women. Women had higher N-terminal pro B-type natriuretic peptide levels (1180 vs 387 ng/L, P = .015), lower cardiac troponin T levels (389 vs 726 ng/L, P = .006), and fewer segments with nonischemic late gadolinium enhancement on cardiac magnetic resonance imaging (1 vs 3, P = .005), but similar left ventricular ejection fraction (55 vs 55%, P = .629), compared with men. Overall, hospital stay was longer in women compared with men (7 vs 5 days, P = .018), with a similar length of intensive care unit stay (2.6 vs 2.7 days, P = .922). Women more often developed severe arrhythmia (8.3 vs 2.2%, P = .015) and heart failure during the hospitalization (31.3 vs 16.4%, P = .003). ConclusionCompared with men, women with acute myocarditis were older at the time of diagnosis, presented more often with heart failure, and had an increased frequency of severe arrhythmia.

Tomographic index (ONSD/ETD) as a predictor of short-term neurological outcome in children with severe traumatic brain injury: A single-center retrospective observational study from Mexico

Abstract Background: Traumatic brain injury (TBI) is a prevalent condition in the pediatric population. An index between the diameter of the optic nerve sheath diameter (ONSD) and the transverse eyeball transverse diameter (ETD) measured in the tomographic scan has been described in adults, with a cutoff value of ≥0.25 for predicting poor neurologic prognoses. This study was conducted to analyze the relationship between the index ONSD/ETD with the neurological outcome in children with severe TBI. Subjects and Methods: This was single-center, retrospective study, conducted from March 2021 to November 2022. Patients older than 30 days and up to 16 years of age admitted with severe TBI were included in the study. Measurements of the ONSD/ETD index by cranial tomography were calculated. The population was divided into two groups, one with index ≥0.25 and other with index &lt;0.25. Glasgow Outcome Scale-Extended (GOSE) and outcome were compared between groups. Results: Thirty patients were recruited. Patients with inde × 0.25 or higher had a lower GOSE (60% (1–2 points) vs. 60% (7–8 points)), more days of mechanical ventilation (MV) (8 days, interquartile range IQR 5–17 days vs. 3 days, IQR 2–4 days P = 0.005), and more length of pediatric intensive care unit (PICU) stay (12 days, IQR 9–23 days vs. 5 days, IQR 4–8 days P = 0.007) than patients with index &lt;0.25. Conclusions: The ONSD/ETD index was a reliable indicator for predicting the neurological outcome of patients with severe TBI. An index ≥0.25 was associated with more days of PICU stay and MV with worse neurological outcomes.

Bilateral internal thoracic artery grafting in robotic beating-heart totally endoscopic coronary artery bypass: 10-year outcomes.

Multi-arterial grafting (MAG) with bilateral internal thoracic arteries (BITAs) is superior to single internal thoracic artery (ITA) and veins, however, sternal wound infection (SWI) is a deterrent to using BITA, especially in diabetic and obese patients. Sternal-sparing approaches, including robotic totally endoscopic coronary artery bypass (TECAB), may mitigate this risk. We reviewed outcomes of robotic TECAB with BITA grafting. A total of 871 patients underwent robotic TECAB at our institution from 7/2013 to 4/2024. Of these, 406 patients received BITA grafts and are the subject of this review. Early and mid-term clinical outcomes were reviewed and angiographic patency in those undergoing hybrid revascularization with percutaneous coronary intervention (PCI) after TECAB. All cases were performed via a beating-heart robotic approach, with standard TECAB port placement. The mean age of the cohort was 67±9 years and 16% were female. The mean Society of Thoracic Surgeons (STS) risk was 1.47%±2.2%. Thirty-nine percent were diabetic (15% insulin-dependent) and 39% had a body mass index (BMI) ≥30 kg/m2. Twenty percent had an ejection fraction (EF) ≤40%. Ninety-eight percent of cases were completed off-pump and there were no conversions to sternotomy. The mean number of grafts per patient was 2.2±0.4. The mean intensive care unit (ICU) and hospital length of stay (LOS) were 1.22±0.62 and 2.44±0.83 days, respectively. Postoperative complications included atrial fibrillation in 13%, acute kidney injury (AKI) in 3.4%, return to theatre for bleeding in 0.7%, postoperative myocardial infarction (MI) in 0.2%, and stroke in 0.2%. Thirty-day mortality was 1.2% [observed/expected (O/E): 0.89]. Return to full activities and work occurred at mean of 14±8.6 and 17±13 days, respectively. Two hundred and two patients (50%) had 'advanced' hybrid revascularization (with at least two arterial grafts and stents). ITA early graft patency in this cohort of patients was 271/278 (98%) with 100% left ITA to left anterior descending artery (LITA-LAD) patency. Mid-term follow-up was complete in all patients at mean of 51±36 months (longest follow-up at 10 years). All-cause mortality was 13% and cardiac-mortality was 2.5%. Freedom from angina was 96%, and freedom from repeat revascularization was 94%. Use of the beating-heart robotic TECAB approach facilitates BITA grafting to achieve multi-vessel arterial revascularization of the left coronary system, with excellent 10-year outcomes.

Enterococcal Bacteremia outbreaks during SARS-COV-2 in Intensive Care Unit (ICU): The role of Strain Identification

Background: An unprecedented burden of morbidity and mortality has been reported in patients admitted to healthcare facilities with SARS-COV-2 infection globally since March 2020. A higher incidence of ICU-acquired bloodstream infection has been described with the cumulative risk increased with the length of ICU stay, use of steroids, anti-inflammatory agents, and indwelling catheters. Additionally, SARS-COV-2 infection may increase the risk of bacteremia from gastrointestinal flora such as Enterococcus species by disrupting the gastrointestinal barrier and microbiome. Methods: We aimed to investigate the outbreaks of Enterococcus bacteremia in patients with SARS-COV-2 infection and included patients aged&gt;18 years admitted to the ICU at the Oklahoma City Veterans Affairs Medical Center who were infected with SARS-COV-2 and were identified as having positive blood cultures for Enterococcus faecalis, Enterococcus faecium including vancomycin-resistant species and other bacterial or candida species between March 1, 2020, to March 9, 2022. We collected the following data: duration of hospitalization including ICU stay, unit and room location during the hospital stay, blood culture collection date and results, duration, and site of central line placement, duration of ventilation, administration of antimicrobials and COVID-19 directed therapeutics using computerized patient record system (CPRS). We sent 10 E. faecalis and 12 E. Faecium isolates for genetic analysis. DNA was sequestered from each isolate and multi-locus sequence typing (MLST) was performed by amplifying 7 regions of the E. faecalis genome and 7 regions of the E. faecium genome by polymerase chain reaction (PCR). Resulting amplicons were sequenced and allele type for each gene region and overall sequence type was determined using MLST database (http://pubmlst.org). Results: There were 22 episodes of enterococcal bacteremia in a 3-month duration in the ICU in 20 patients of which 17 were associated with another episode with the same strain (Figure-1-2). Central line placement was noted in 18/22 episodes. Genetic analysis by multi-locus sequence typing of enterococcal bacterial strains was performed by the Public Health Reference Laboratory, Palo Alto. Similar strains were localized to patients in the same geographical region in the ICU (Figure 3). The isolates from 2 other patients who presented with the same strain of Enterococcus but were never hospitalized at the same time during the COVID-19 pandemic were localized to another hospital where both had received care at different times. Conclusion: Higher rates of enterococcal bacteremia were reported during the SARS-COV-2 pandemic. Geographical proximity with strained infection control measures accounted for ICU outbreaks seen in our tertiary care setup.

Ulinastatin shortens the length of ICU stay in critical patients with organ failure: A 7-year real-world study.

Ulinastatin has been applied in a series of diseases associated with inflammation but its clinical effects remain somewhat elusive. We aimed to investigate the potential effects of ulinastatin on organ failure patients admitted to the intensive care unit (ICU). This is a single-center retrospective study on organ failure patients from 2013 to 2019. Patients were divided into two groups according to using ulinastatin or not during hospitalization. Propensity score matching was applied to reduce bias. The outcomes of interest were 28-day all-cause mortality, length of ICU stay, and mechanical ventilation duration. Of the 841 patients who fulfilled the entry criteria, 247 received ulinastatin. A propensity-matched cohort of 608 patients was created. No significant differences in 28-day mortality between the two groups. Sequential organ failure assessment (SOFA) was identified as the independent risk factor associated with mortality. In the subgroup with SOFA ≤ 10, patients received ulinastatin experienced significantly shorter time in ICU (10.0 d [interquartile range, IQR: 7.0∼20.0] vs 15.0 d [IQR: 7.0∼25.0]; p = .004) and on mechanical ventilation (222 h [IQR:114∼349] vs 251 h [IQR: 123∼499]; P = .01), but the 28-day mortality revealed no obvious difference (10.5% vs 9.4%; p = .74). Ulinastatin was beneficial in treating patients in ICU with organ failure, mainly by reducing the length of ICU stay and duration of mechanical ventilation.

Factors Associated With Quality-of-Dying-and-Death Classes Among Critically Ill Patients

Improving end-of-life care in the intensive care unit (ICU) is a priority, but clinically modifiable factors of quality of dying and death (QODD) are seldom identified. To comprehensively identify factors associated with QODD classes of dying ICU patients, emphasizing clinically modifiable factors based on the integrative framework of factors associated with for bereavement outcomes. This observational cohort study was conducted at medical ICUs of 2 Taiwanese medical centers from January 2018 to March 2020 with follow-up through December 2022. Eligible participants included primary family surrogates responsible for decision making for critically ill ICU patients at high risk of death (Acute Physiology and Chronic Health Evaluation II score >20) but who survived more than 3 days after ICU admission. Data analysis was conducted from July to September 2023. QODD was measured by the 23-item ICU-QODD questionnaire. Factors associated with patient membership in 4 previously determined QODD classes (high, moderate, poor to uncertain, and worst) were examined using a 3-step approach for latent class modeling with the high QODD class as the reference category. A total of 309 family surrogates (mean [SD] age, 49.83 [12.55] years; 184 women [59.5%] and 125 men [40.5%]) were included in the study. Of all surrogates, 91 (29.4%) were the patients' spouse and 66 (53.7%) were the patients' adult child. Patient demographics were not associated with QODD class. Two family demographics (age and gender), relationship with the patient (spousal or adult-child), and length of ICU stay were associated with QODD classes. Patients of surrogates perceiving greater social support were less likely to be in the poor to uncertain (adjusted odds ratio [aOR], 0.89; 95% CI, 0.83-0.94) and worst (aOR, 0.92; 95% CI, 0.87-0.96) QODD classes. Family meetings were associated with the poor to uncertain QODD class (aOR, 8.61; 95% CI, 2.49-29.74) and worst QODD class (aOR, 7.28; 95% CI, 1.37-38.71). Death with cardiopulmonary resuscitation was associated with the worst QODD class (aOR, 7.51; 95% CI, 1.12-50.25). Family presence at patient death was uniformly negatively associated with the moderate QODD class (aOR, 0.16; 95% CI, 0.05-0.54), poor to uncertain QODD class (aOR, 0.21; 95% CI, 0.05-0.82), and worst QODD class (aOR, 0.08; 95% CI, 0.02-0.38). Higher family satisfaction with ICU care was negatively associated with the poor to uncertain QODD class (aOR, 0.93; 95% CI, 0.87-0.98) and worst QODD class (aOR, 0.86; 95% CI, 0.81-0.92). In this cohort study of critically ill patients and their family surrogates, modifiable end-of-life ICU-care characteristics played a more significant role in associations with patient QODD class than did immutable family demographics, preexisting family health conditions, patient demographics, and patient clinical characteristics, thereby illuminating actionable opportunities to improve end-of-life ICU care.

Predictors of Renal Replacement Therapy in Cardiac Surgery-Associated Acute Kidney Injury Patients: A Single-Centered, Retrospective Study

Abstract Background: Studies have reported that cardiac surgery-associated acute kidney injury (CSA-AKI) patients requiring dialysis or renal replacement therapy (RRT) have a higher risk of in-hospital mortality. This study aimed to investigate the predictors contributing to postoperative RRT. Materials and Methods: This retrospective observational study was conducted at a single cardiovascular center. Patients who underwent cardiac surgery complicated with CSA-AKI in the intensive care unit (ICU) from January 2020 to December 2022 were included. They were categorized into two groups: those who required RRT (group A, n = 302) and those who did not (group B, n = 811). Bivariable and multivariable analyzes were conducted to compare the risk with odds ratio (OR) for in-hospital mortality between those groups. Results: We analyzed 1113 patients (29.4%) in the final analysis. The in-hospital mortality rate was 31.8% vs. 4.2% (OR = 10.6, P &lt; 0.001). Variables that significantly predicted postoperative RRT requirements in CSA-AKI patients included female sex (P = 0.038), coronary artery bypass graft (P = 0.001), multiple valves surgery (P = 0.032), diabetes (P = 0.01), renal disease (P = 0.005), postoperative serum creatinine &gt;3.0 mg/dL (P &lt; 0.001), mechanical ventilation use of ≥48 h (P &lt; 0.001), ICU length of stay of &gt;5 days (P &lt; 0.001), use of more than two inotropes and vasoactive agents, (P &lt; 0.001), and postoperative intra-aortic balloon pump (IABP) (P &lt; 0.001). Conclusion: CSA-AKI patients who require dialysis are associated with a higher mortality. Predictors of postoperative RRT included female sex, certain types of surgery, diabetes, postoperative serum creatinine &gt;3.0 mg/dL, mechanical ventilation use of ≥48 h, ICU length of stay of &gt;5 days, use of more than two inotropes and vasoactive agents, and postoperative IABP.

Unveiling the Correlation between Transferrin Saturation and Critically Ill COVID-19 Patients’ Outcomes: A Multicenter Cohort Study

Abstract Background: Critically ill patients with coronavirus disease 2019 (COVID-19) often have cytokine storms, manifested with elevated levels of proinflammatory biomarkers and hyperferritinemia. Systemic inflammation significantly limits the iron availability for erythropoiesis, which may disturb iron homeostasis and affect clinical outcomes. Thus, this study aimed to evaluate the impact of iron hemostasis on the clinical outcomes of critically ill patients with COVID-19. Materials and Methods: A multicenter, retrospective cohort study was conducted and included critically ill adult COVID-19 patients admitted to the intensive care units (ICUs) from March 2020 to July 2021. Patients were categorized based on transferrin saturation (TSAT) during their ICU stay (TSAT &lt; 20% vs. TSAT ≥ 20%). The primary outcome was the in-hospital mortality, while other outcomes were considered secondary. Results: After propensity score matching (PSM) (1:1 ratio), 46 patients were included in the final analysis. In-hospital mortality was not statistically significantly different between the two groups (OR, 0.91; 95% CI, 0.29–2.87; P = 0.88). Patients with TSAT ≥ 20% had a longer mechanical ventilation duration (beta coefficient 0.11; 95% CI, −0.54–0.76; P = 0.19); however, it did not reach statistical significance. Moreover, the ICU length of stay (LOS) and hospital LOS were not statistically significant in patients with a TSAT ≥ 20%. Conclusion: Our results show no significant differences in clinical outcomes between patients with TSAT levels ≥20% and those with TSAT &lt; 20%. Larger prospective studies are needed to verify these findings and evaluate the effect of iron correction on anemic patients’ outcomes.

A Retrospective Comparison of Clinical and Laboratory Aspects of Patients With COVID-19-Related Acute Respiratory Distress Syndrome (ARDS) and Non-COVID-19-Related ARDS.

This study investigated demographic characteristics, hemodynamic values, respiratory datas, laboratory values ​​such as biochemistry and blood gas, and treatment approaches of coronavirus disease 2019 (COVID-19)-related and non-COVID-19-related acute respiratory distress syndrome (ARDS) patients hospitalized in the intensive care unit (ICU). Determining the differences and similarities between COVID-19-related ARDS (CARDS) patients and non-COVID-19-related ARDS (NCARDS) patients will be useful to better understand these two diseases. A total of 32 NCARDS patients who were followed and treated in the ICU for various reasons between January 2015 and December 2020 and 32 CARDS patients who were followed and treated in the ICU for various reasons between March 2020 and December 2020 were examined retrospectively. Age, gender, comorbidities, Glasgow Coma Scale (GCS), Acute Physiology and Chronic Health Evaluation (APACHE) II Score, blood pressure, heart rate, saturation, laboratory results, arterial blood gas (ABG) values, length of stay in the ICU, intubation, the number of days till the patient was extubated, the treatments applied, admission to the service, and mortality were evaluated. In the comparison between the two groups, the demographic data of the patients, the number of days intubated and extubated, APACHE II scores, and ICU length of stay were not statistically different. Values of positive end-expiratory pressure (PEEP), first hospitalization GCS, first hospitalization hemoglobin (Hgb), albumin at first admission, alanine aminotransferase (ALT) at first admission, and steroid use were found to be significantly different in patients with CARDS (p < 0.001). The median of PEEP values (p = 0.04), first admission GCS values (p = 0.04), first admission Hgb values (p = 0.005), albumin values at the first admission (p = 0.03), ALT values (p = 0.03), and the rate of steroid use (p = 0.001) of CARDS patients were significantly higher than those of NCARDS patients. The median of the first hospitalization heart rate values (p = 0.009), first hospitalization saturation values (p = 0.001), and first admission neutrophil values (p = 0.03) in NCARDS patients were significantly higher than that of CARDS patients. There was no significant difference between the two groups in terms of mortality, sedation use, inotropic support, C-reactive protein (CRP), and procalcitonin values. CARDS and NCARDS have clinical and laboratory similarities and differences. Therefore, there should be differences in our follow-up and treatment approach to these two disease groups.

Comparison Between Early and Late Tracheostomy in ICU Patients Including COVID-19 and Non-COVID-19 Patients: A Retrospective Cohort Study at a Tertiary Care Hospital.

Background Tracheostomy is a common intervention for intensive care unit (ICU) patients for various reasons. The superiority of early versus late tracheostomy is still unfounded for non-COVID-19 cases. The COVID-19 pandemic complicated the matter, as little literature was available on the ideal timing of tracheostomy for patients with COVID-19. Research question This study aimed to establish the superiority of early or late tracheostomy for COVID-19 and non-COVID-19 cases by comparing outcomes, including ICU mortality, ventilation days after tracheostomy, and ICU length of stay (LOS). Study design and methods A single-center retrospective cohort study was conducted on ventilated ICU patients both with and without COVID-19 at a university hospital between January 2020 and December 2021. During the study period, 1,393 ventilated patients were scanned, and 156 were found to be tracheostomized. Tracheostomy was considered to be early when performed within 10 days of intubation, after which it was considered to be late. Results Tracheostomy was performed early for 84/156 (53.8%) of tracheostomized patients and late for 72/156 (46.2%) of patients. The overall mortality was 42.9% (36/84) versus 69.4% (50/72) (P=0.001, OR=3.03, 95% CI=1.563-5.874), 31.4% versus 65.5% in the non-COVID-19 group and 60.6% versus 72.1% (P=0.005, OR=2.640, 95% CI=1.345-5.181) in the COVID-19 group for the early and late tracheostomy groups, respectively. Ventilation days were higher for the late tracheostomy group than for the early tracheostomy group in the non-COVID-19 group (17.10 versus 9.18 days, P<0.001). However, it was almost the same for the early and late tracheostomy groups in the COVID-19 group (14.15 versus 13.86 days,P=0.821). The ICU LOS was greater for the late tracheostomy group for both the COVID-19 and non-COVID-19 groups. Multivariate analysis revealed that ICU mortality is significantly associated with age, ventilation days, and ICU LOS. Interpretation The results of this study indicate that early tracheostomy was associated with lower mortality, fewer ventilation days, and shorter LOS in both the COVID-19 and non-COVID-19 groups.