Lower Intensive Care Unit Mortality Research Articles

Early deep-to-light sedation versus continuous light sedation for ICU patients with mechanical ventilation: A cohort study

BackgroundSedation strategies have not been well established for patients being treated with invasive mechanical ventilation (MV). This study aimed to compare the potential effects of alternative sedation strategies – including early deep-to-light sedation (DTLS), continuous deep sedation (CDS) and continuous light sedation (CLS, the currently recommended strategy) – on ventilator, intensive care unit (ICU) or hospital mortality. MethodsA cohort study was conducted using two large validated ICU databases, including the Registry of Healthcare-associated Infections in ICUs in China (ICU-HAI) and the Medical Information Mart for Intensive Care (MIMIC). Patients who received MV for more than 3 days with one of three sedation strategies were included. Multivariable survival analyses with inverse probability-weighted competing risk models were conducted separately for ICU-HAI and MIMIC cohorts. Adjusted estimates were pooled using fixed-effects models. ResultsIn total, 6700 patients (2627 ICU-HAI, 4073 MIMIC) were included in the cohort study, of whom 2689 received CLS, 2079 CDS and 1932 DTLS. Compared to CLS, DTLS was associated with lower ICU mortality (9.3% vs. 11.0%; pooled adjusted HR 0.78, 95% CI 0.66−0.94) and hospital mortality (16.0% vs. 14.1%; 0.86, CI 0.74–1.00); and CDS was associated with higher ventilator mortality (32.8% vs. 7.0%; 4.65, 3.91–5.53), ICU mortality (40.6% vs. 11.0%; 3.39, 2.95–3.90) and hospital mortality (46.8% vs. 14.1%; 3.27, 2.89–3.71) than CLS. All HRs were qualitatively consistent in both cohorts. ConclusionsCompared to the continuous light sedation, early deep-to-light sedation strategy was associated with improved patient outcomes, and continuous deep sedation was confirmed with poorer patient outcomes.

A tidal volume of 7 mL/kg PBW or higher may be safe for COVID-19 patients

PurposeThe novel coronavirus disease (COVID-19) has revived the debate on the optimal tidal volume during acute respiratory distress syndrome (ARDS). Some experts recommend 6 mL/kg of predicted body weight (PBW) for all patients, while others suggest 7–9 mL/kg PBW for those with compliance >50 mL/cmH2O. We investigated whether a tidal volume ≥ 7 ml/kg PBW may be safe in COVID-19 patients, particularly those with compliance >50 mL/cmH2O. Materials and methodsThis secondary analysis of a multicenter study compares the Intensive Care Unit (ICU) mortality among 600 patients ventilated with <7 or ≥ 7 mL/kg PBW. Compliance was categorized as <40, 40–50, or > 50 mL/cmH2O. Results346 patients were ventilated with <7 (6.2 ± 0.5) mL/kg PBW and 254 with ≥7 (7.9 ± 0.9) mL/kg PBW. ICU mortality was 33 % and 29 % in the two groups (p = 0.272). At multivariable regression analysis, tidal volume ≥ 7 mL/kg PBW was associated with lower ICU mortality in the overall population (odds ratio: 0.62 [95 %-confidence interval: 0.40–0.95]) and in each compliance category. ConclusionsA tidal volume ≥ 7 (up to 9) mL/kg PBW was associated with lower ICU mortality in these COVID-19 patients, including those with compliance <40 mL/cmH2O. This finding should be interpreted cautiously due to the retrospective study design.Trial registration: ClinicalTrails.govNCT04388670.

Impact of the timing of invasive mechanical ventilation in patients with sepsis: a multicenter cohort study

BackgroundThe potential adverse effects associated with invasive mechanical ventilation (MV) can lead to delayed decisions on starting MV. We aimed to explore the association between the timing of MV and the clinical outcomes in patients with sepsis ventilated in intensive care unit (ICU).MethodsWe analyzed data of adult patients with sepsis between September 2019 and December 2021. Data was collected through the Korean Sepsis Alliance from 20 hospitals in Korea. Patients who were admitted to ICU and received MV were included in the study. Patients were divided into ‘early MV’ and ‘delayed MV’ groups based on whether they were on MV on the first day of ICU admission or later. Propensity score matching was applied, and patients in the two groups were compared on a 1:1 ratio to overcome bias between the groups. Outcomes including ICU mortality, hospital mortality, length of hospital and ICU stay, and organ failure at ICU discharge were compared.ResultsOut of 2440 patients on MV during ICU stay, 2119 ‘early MV’ and 321 ‘delayed MV’ cases were analyzed. The propensity score matching identified 295 patients in each group with similar baseline characteristics. ICU mortality was lower in ‘early MV’ group than ‘delayed MV’ group (36.3% vs. 46.4%; odds ratio, 0.66; 95% confidence interval, 0.47–0.93; p = 0.015). ‘Early MV’ group had lower in-hospital mortality, shorter ICU stay, and required tracheostomy less frequently than ‘delayed MV’ group. Multivariable logistic regression model identified ‘early MV’ as associated with lower ICU mortality (odds ratio, 0.38; 95% confidence interval, 0.29–0.50; p < 0.001).ConclusionIn patients with sepsis ventilated in ICU, earlier start (first day of ICU admission) of MV may be associated with lower mortality.

The effect of protein administration during critical illness depends on body composition: A secondary analysis of a prospective, observational study

Background & AimsThe most adequate amount of protein that should be administered to critically ill patients is still debated and diverging findings are recently accumulating. We hypothesized that the effect of protein administration might depend on the amount of muscle mass. MethodsA secondary analysis of a single-centre prospective observational study of body composition in critically ill patients. Mechanically-ventilated subjects with an expected intensive care unit (ICU) stay >72h were enrolled. Within 24h from ICU admission, bioimpedance-derived muscle mass (BIA MM) and rectus femoris cross-sectional area (RF CSA) were measured. The amount of proteins and calories administered on the 7th ICU day was recorded. ResultsWe enrolled 94 subjects (65 males, actual body weight 72.9±14.4 Kg, BMI 26.0±4.8 kg/m2). Actual body weight was only weakly related to BIA MM (R=0.478, p<0.001) and not related to RF CSA (R=0.114, p=0.276). A higher protein intake was associated with a reduced mortality in the highest quartile of BIA MM (OR 0.68 [0.46; 0.99] per each 10g of proteins administered) and in the third (OR 0.74 [0.57; 0.98]) and highest quartile of RF CSA (OR 0.68 [0.48; 0.96]). ConclusionA higher protein intake was associated with lower ICU mortality only in patients admitted with a higher muscle mass, as either assessed by BIA or muscle ultrasound.

Effect of propofol versus midazolam on short-term outcomes in patients with sepsis-associated acute kidney injury.

Propofol and midazolam are commonly used sedative drugs in mechanically ventilated patients in the Intensive Care Unit (ICU). However, there is still a lack of relevant studies exploring the influence of midazolam and propofol on the prognosis of patients with Sepsis-associated Acute Kidney Injury (S-AKI). A statistical analysis was conducted on 3,745 patients with S-AKI in the Medical Information Mart for Intensive Care IV database. The patients' baseline characteristics were grouped based on the use of either propofol or midazolam as sedatives. Cox proportional hazards models, logistic regression models, and subgroup analyses were used to compare the effects of propofol and midazolam on the short-term prognosis of S-AKI patients, including 30-day mortality, ICU mortality, and duration of mechanical ventilation. In the statistical analysis, a total of 3,745 patients were included, with 649 patients using midazolam and 3,096 patients using propofol. In terms of the 30-day mortality, compared to patients using midazolam, S-AKI patients using propofol had a lower ICU mortality (hazard ratio = 0.62, 95% confidence interval: 0.52-0.74, p < 0.001), lower 30-day mortality (hazard ratio = 0.56, 95% confidence interval: 0.47-0.67, p < 0.001), and shorter mechanical ventilation time (odds ratio = 0.72, 95% confidence interval: 0.59-0.88, p < 0.001). Kaplan-Meier curves showed lower survival probabilities in the midazolam group (p < 0.001). Subgroup analyses showed that propofol was strongly protective of short-term prognosis in older, male, smaller SOFA score CCI score, no heart failure, and comorbid chronic kidney disease patients with S-AKI. Compared to midazolam, propofol was considered a protective factor for short-term mortality risk and ICU mortality risk in S-AKI patients. Additionally, S-AKI patients using propofol had a lower risk of requiring prolonged mechanical ventilation. Overall, propofol may be more beneficial for the short-term prognosis of S-AKI patients compared to midazolam.

Impact of Critical Care Registered Dietitian on Clinical Outcomes of Neurocritically Ill Patients

Background: To investigate the impact of early nutrition intervention and a critical care registered dietitian on the outcomes of neurocritically ill patients.Methods: Among neurosurgical patients admitted to the intensive care unit (ICU) in a tertiary hospital from January 2015 to December 2019, A critical care registered dietitian co-management was initiated on May 1, 2017. The primary endpoint was ICU mortality. Propensity score matching (PSM) was used to control selection bias and confounding factors.Results: In this study, 1,386 patients were included. In the overall study population, nutrition was provided to 719 (51.9%) patients under the supervision of a registered dietitian. Early nutrition was performed for 356 (25.7%) patients. In the overall study population and the PSM adjusted population, rates of early parenteral nutrition (EPN) were higher in the groups managed by a registered dietitian than in the group without a registered dietitian (both p &lt;0.001). In the overall and PSM adjusted population, the rates of ICU mortality, 28-day mortality, and in-hospital mortality were not significant different between two groups (all p &gt; 0.05), but the group managed by a registered dietitian had a shorter hospital stay than the group without a registered dietitian (both p &lt;0.02). In the multivariable analysis of the overall population and PSM adjusted population, EPN showed an association with ICU mortality. Conclusions: The rate of EPN utilization increased after the implementation of co-management with a critical care registered dietitian, and the use of EPN was associated with lower ICU mortality in neurocritically ill patients.

Effect of improved nursing strategy on prognosis of older immunosuppressed patients with pneumonia and sepsis

To investigate the effect of improved nursing strategy on prognosis of older immunosuppressed patients with pneumonia and sepsis. A prospective study was conducted. The older immunosuppressed patients with pneumonia and sepsis admitted to the department of intensive care medicine and emergency intensive care unit (ICU) of Peking Union Medical College Hospital from January 2017 to July 2022 were enrolled. In the first stage (from January 2017 to December 2019), patients received the original nursing strategy (original nursing strategy group), including: (1) nurses were randomly assigned; (2) routine terminal cleaning; (3) ICU environmental cleaning twice a day; (4) oral care was performed with chlorhexidine twice a day; (5) original lung physiotherapy [head of bed elevated at 30 degree angle-45 degree angle, maintaining a Richmond agitation-sedation scale (RASS) -2 to 1, sputum aspiration as needed]. After 1 month of learning and training of the modified nursing treatment strategy for nurses and related medical staff, the patients in the second stage (from February 2020 to July 2022) received the improved nursing strategy (improved nursing strategy group). The improved nursing strategy improved the hospital infection prevention and control strategy and lung physical therapy strategy on the basis of the original nursing strategy, including: (1) nurses were fixed assigned; (2) patients were placed in a private room; (3) enhanced terminal cleaning; (4) ICU environmental cleaning four times a day; (5) education and training in hand hygiene among health care workers was improved; (6) bathing with 2% chlorhexidinegluconate was performed once daily; (7) oral care with a combination of chlorhexidine and colistin was provided every 6 hours; (8) surveillance of colonization was conducted; (9) improved lung physiotherapy (on the basis of the original lung physiotherapy, delirium score was assessed to guide early mobilization of the patients; airway drainage was enhanced, the degree of airway humidification was adjusted according to the sputum properties, achieving sputum viscosity grade II; lung ultrasound was also used for lung assessment, and patients with atelectasis were placed in high lateral position and received the lung recruitment maneuver). Baseline patient information were collected, including gender, age, underlying diseases, source of admission, disease severity scores, vital signs, ventilatory parameters, blood gas analysis, life-sustaining treatments, clinical laboratory evaluation, indicators of infection and inflammation, pathogens and drug therapy. The primary outcome was 28-day mortality, and the secondary outcomes were duration of mechanical ventilation, length of ICU stay, and ICU mortality. Multivariate Logistic regression analysis was used to determine the risk factors for 28-day death in older immunosuppressed patients with pneumonia and sepsis. Finally, 550 patients were enrolled, including 199 patients in the original nursing strategy group and 351 patients in the improved nursing strategy group. No significant differences were found in gender, age, underlying diseases, source of admission, disease severity scores, vital signs, ventilatory parameters, blood gas analysis, life-sustaining treatments, clinical laboratory evaluation, indicators of infection and inflammation, coexisting pathogens or drug therapy between the two groups. Compared with patients in the original nursing strategy group, those in the improved nursing strategy group had significantly fewer duration of mechanical ventilation and length of ICU stay [duration of mechanical ventilation (days): 5 (4, 7) vs. 5 (4, 9), length of ICU stay (days): 11 (6, 17) vs. 12 (6, 23), both P < 0.01], and lower ICU mortality and 28-day mortality [ICU mortality: 23.9% (84/351) vs. 32.7% (65/199), 28-day mortality: 23.1% (81/351) vs. 33.7% (67/199), both P < 0.05]. Multivariate Logistic regression analysis showed that the improved nursing strategy acted as an independent protective factor in 28-day death of older immunosuppressed patients with pneumonia and sepsis [odds ratio (OR) = 0.543, 95% confidence interval (95%CI) was 0.334-0.885, P = 0.014]. Improved nursing strategy shortened the duration of mechanical ventilation and the length of ICU stay, and decreased ICU mortality and 28-day mortality in older immunosuppressed patients with pneumonia and sepsis, significantly improving the short-term prognosis of such patients.

Epidemiology, Clinical Characteristics, and Outcomes of Culture-negative Sepsis

Aim: Culture-negative sepsis (CNS) is a common but understudied entity. The objective of this study was to compare the incidence, characteristics, and outcomes of CNS with culture-positive sepsis (CPS). Methods: This was a prospective observational study of patients admitted to the medical intensive care unit (ICU) of a tertiary hospital from January to December 2015 with clinical suspicion of severe sepsis as defined by Consensus Conference Criteria 2001. Results: Patients with severe sepsis ( n = 122) were studied of whom 66 (54%) were CPS and 56 (46%) were CNS. Patients with CNS had fewer comorbidities (0.7 ± 0.70 vs. 2 ± 0.8, P &lt; 0.01). At presentation, CNS patients had less tachycardia (heart rate 92.5 ± 10.5 vs. 105.9 ± 13.2, P &lt; 0.01), lower white blood cell counts (11859 ± 4791 vs. 14224 ± 3898, P = 0.003), lower need for vasopressors (38% vs. 68%, P &lt; 0.01), and mechanical ventilation (23% vs. 53%, P &lt; 0.01) compared to patients with CPS. The number of antibiotics on admission was similar between the groups (1.5 ± 0.6 vs. 1.6 ± 0.6, P = 0.36) but the duration of antibiotics was less in CNS (7.6 ± 1.7 days vs. 10.4 ± 2.6 days, P &lt; 0.01). CNS had lower duration of ICU stay (6 ± 2.1 days vs. 7.8 ± 3.7 days, P &lt; 0.01) and lower ICU mortality (7.1% vs. 22.7%, P = 0.02). Conclusion: CNS is very common in ICU. CNS patients compared to CPS tend to be less sick at presentation utilizing less resources but were initiated on a similar number of antibiotics on admission although for a shorter duration. Patients with CNS had a lower mortality in comparison to those with CPS.

Early sodium bicarbonate therapy for critically ill patients with septic shock and acute moderate metabolic acidosis

To the editor: In recent decades, septic shock has continued to be a life-threatening health problem around the world.[1] Meanwhile, metabolic acidosis (MA) is also well known in critically ill patients, and even moderate metabolic acidosis (MMA) is associated with higher mortality than sepsis.[2] Although the administration of sodium bicarbonate (SB) is widely used in sepsis shock with MA in the intensive care unit (ICU), its clinical efficacy is not well established. In the 2021 update of the Surviving Sepsis Campaign guidelines, Evans et al. recommend the administration of SB in adults with septic shock, severe metabolic acidemia (pH ≤7.2), and acute kidney injury (AKI, AKIN score 2 or 3).[3,4] However, clinical evidence for the efficacy of the administration of SB in critically ill patients with septic shock and acute MMA is still limited. We retrospectively investigated a large ICU database (MIMIC-IV, https://www.physionet.org/) from 2008 to 2019 in 6 ICUs at a single-center hospital (Beth Israel Deaconess Medical Centre; Boston, MA). All adults with septic shock and acute MMA (7.2 < pH < 7.3, bicarbonate concentration <20 mmol/L, and PaCO2 <50 mmHg) within the first 48 hours after ICU admission were included in this study. Propensity score analysis[5] (PSA) was performed to account for differences in the probability of receiving or not receiving SB. For the PSA, we matched patients 1 to 1. The marginal structural Cox model[5] (MSCM) was developed to adjust for both baseline and time-varying confounding variables. The primary outcome was ICU and in-hospital mortality. Variables, including sex, age, body mass index, comorbidities on ICU admission, mechanical ventilation, vasopressors, and renal replacement therapy, were extracted from the MIMIC-IV database for the first 24 hours of ICU admission. Serum creatinine within the first 48 hours of an ICU stay was used to identify AKI stages. Administration of lactate solution for the first 24 hours was also included in the study. To account for the possible influence of clinical practice in previous years, the year of admission was used as a random factor in a mixed-effects model. Laboratory variables (PaO2, PaCO2, pH, and bicarbonate concentration) were recorded throughout the ICU period. For patients who underwent multiple tests, the highest values of lactate and PaCO2 and the lowest values of PaO2, bicarbonate concentration, and pH on each day were used for analysis. The above variables included in the PSA and MSCM are listed in Supplemental Table 1 (https://links.lww.com/ECCM/A58). A total of 577 patients with septic shock and MMA were identified, of whom 194 were included in the SB and 383 in the non-SB groups (Supplemental Table 2, https://links.lww.com/ECCM/A58). In the PSA group, early SB infusion was associated with both lower ICU mortality (hazards ratio [HR]: 0.61; 95% confidence interval [CI]: 0.40–0.93; P < 0.05) and lower in-hospital mortality (HR: 0.69; 95% CI: 0.50–0.97; P < 0.05; Fig. 1). In MSCM, our study also found a statistically significant positive effect of early SB infusion on ICU mortality (HR: 0.31; 95% CI: 0.13–0.72; P < 0.01) and hospital mortality (HR: 0.55; 95% CI: 0.31–0.97; P < 0.05) in patients with septic shock and MMA (Supplementary Figure 1, https://links.lww.com/ECCM/A59).Figure 1: Forest plot showing the effect of early sodium bicarbonate infusion on ICU and hospital mortality in the PSA for critically ill patients with septic shock and acute moderate metabolic acidosis. The hazard ratios were estimated using the PSA. After propensity score matching, 194 patients from the non-SB group were matched to SB group (n = 194) to balance the baseline differences in the probability to receive SB or not. The x-axis tick marks follow a logarithmic scale. ICU, intensive care unit; PSA, propensity score analysis; SB, sodium bicarbonate.Our observational study suggests that early infusion of SB in critically ill adult patients with septic shock and MMA within the first 48 hours after ICU admission has a significant beneficial effect on both ICU and hospital mortality. Further large, randomized, controlled clinical trials are needed to provide high-quality evidence to improve the Surviving Sepsis Campaign guidelines.

Adherence to protective mechanical ventilation in COVID-19 versus non-COVID-19-associated acute respiratory distress syndrome: Comparison between two prospective cohorts

ObjectiveTo compare adherence to protective mechanical ventilation (MV) parameters in patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 with patients with ARDS from other etiologies. DesignMultiple prospective cohort study.Setting: Two Brazilian cohorts of ARDS patients were evaluated. One with COVID-19 patients admitted to two Brazilian intensive care units (ICUs) in 2020 and 2021 (C-ARDS, n=282), the other with ARDS-patients from other etiologies admitted to 37 Brazilian ICUs in 2016 (NC-ARDS, n=120).Patients: ARDS patients under MV.Interventions: None.Main variables of interest: Adherence to protective MV (tidal volume ≤8mL/kg PBW; plateau pressure ≤30cmH2O; and driving pressure ≤15cmH2O), adherence to each individual component of the protective MV, and the association between protective MV and mortality. ResultsAdherence to protective MV was higher in C-ARDS than in NC-ARDS patients (65.8% vs. 50.0%, p=0.005), mainly due to a higher adherence to driving pressure ≤15cmH2O (75.0% vs. 62.4%, p=0.02). Multivariable logistic regression showed that the C-ARDS cohort was independently associated with adherence to protective MV. Among the components of the protective MV, only limiting driving pressure was independently associated with lower ICU mortality. ConclusionsHigher adherence to protective MV in patients with C-ARDS was secondary to higher adherence to limiting driving pressure. Additionally, lower driving pressure was independently associated with lower ICU mortality, which suggests that limiting exposure to driving pressure may improve survival in these patients.

Systemic thrombolytics as rescue therapy for COVID-19 patients with acute respiratory distress syndrome: A retrospective observational study.

Coronavirus disease 2019 (COVID-19) pneumonia with severe acute respiratory distress syndrome (ARDS) is often associated with a progressive respiratory failure that is refractory to maximal ventilatory support and other ARDS strategies. Studies show evidence of a hypercoagulable state in COVID-19 patients, including capillary thrombosis and alveolar fibrin deposits which impede normal gas exchange. In this context, thrombolysis is considered as a salvage therapy to rescue critically hypoxemic patients. In this retrospective observational study, the efficacy of thrombolysis on outcome of COVID-19 ARDS with respiratory failure was analyzed. Patients with severe ARDS and d-dimer levels of 5 μg/ml or above were initiated on alteplase, as a 25 mg bolus followed by a 25 mg infusion over 22 h. Primary outcome was intensive care unit (ICU) mortality and secondary outcomes were change in PaO2/FiO2 24 h after thrombolysis, avoidance of intubation, ventilator free days (VFD), and ICU and hospital length-of-stay (LOS). Thirteen out of 34 patients with severe COVID ARDS underwent thrombolysis. They had lower ICU mortality than non-thrombolysed patients (23.1% vs. 71.4%, P = 0.006), greater percentage improvement in PaO2/FiO2 (116% vs. 31.5%, P = 0.002), more VFDs (13 days vs. 0 day, P = 0.004), and lesser requirement for intubation (23.1% vs. 76.2%, P = 0.004). ICU and hospital LOS were similar. Thrombolysis can be considered as a rescue therapy for nonintubated COVID-19 ARDS patients with severe hypoxemic respiratory failure, who show evidence of a procoagulant state. Larger studies are needed before inclusion into the regular treatment protocol for COVID-19 patients.

Correlation of central venous-to-arterial carbon dioxide difference to arterial-central venous oxygen difference ratio to lactate clearance and prognosis in patients with septic shock: A prospective observational cohort study.

To assess the relationship between the ratio of difference of venoarterial CO2 tension (P (v-a) CO2) and difference of arterio-venous oxygen content (C (a-cv) O2), i.e., ΔPCO2/ΔCaO2 with lactate clearance (LC) at 8 and 24 h, to define a cutoff for the ratio to identify LC >10% and >20% at 8 and 24 h, respectively, and its association with prognosis in septic shock. Adult patients with septic shock were included in this prospective, observational cohort study. Blood samples for arterial lactate, arterial, and central venous oxygen and carbon dioxide were drawn simultaneously at time zero (T0), 8 h (T8), and 24 h (T24). At T8, patients were divided into Group 8A (LC ≥10%) and Group 8B (LC <10%). At T24, patients were divided into Group 24A (LC ≥20%) and Group 24B (LC <20%). Ninty-eight patients were included. The area under the curve of ΔPCO2/ΔCaO2 at T8 (0.596) and T24 (0.823) was the highest when compared to P(v-a) CO2 and C(a-v) O2. The best cutoff of P(v-a) CO2/C (a-v) O2 as predictor of LC >10% was 1.31 (sensitivity 70.6% and specificity 53.3%) and for LC >20% was 1.37 (sensitivity 100% and specificity 50%). At both T8 and T24, P(v-a) CO2/C (a-v) O2 showed a significant negative correlation with LC. Groups 8A and 24A showed lower intensive care unit mortality than 8B and 24B, respectively. Values of P(v-a) CO2/C (a-v) O2 at T8 were comparable, but at T24, there was a significant difference between the survivors and nonsurvivors (P < 0.001). ΔPCO2/ΔCaO2 predicts lactate clearance, and its 24 h value appears superior to the 8-h value in predicting LC and mortality in septic shock patients.

Multidrug-Resistant Infections and Outcome of Critically Ill Patients with Coronavirus Disease 2019: A Single Center Experience.

Background: The aim of this study was to assess the drivers of multidrug-resistant (MDR) bacterial infection development in coronavirus disease 2019 (COVID-19) and its impact on patient outcome. Methods: Retrospective analysis on data from 32 consecutive patients with COVID-19, admitted to our intensive care unit (ICU) from March to May 2020. Outcomes considered were MDR infection and ICU mortality. Results: Fifty percent of patients developed an MDR infection during ICU stay after a median time of 8 [4-11] days. Most common MDR pathogens were carbapenem-resistant Klebsiella pneumoniae and Acinetobacter baumannii, causing bloodstream infections and pneumonia. MDR infections were linked to a higher length of ICU stay (p = 0.002), steroid therapy (p = 0.011), and associated with a lower ICU mortality (odds ratio: 0.439, 95% confidence interval: 0.251-0.763; p < 0.001). Low-dose aspirin intake was associated with both MDR infection (p = 0.043) and survival (p = 0.015). Among MDR patients, mortality was related with piperacillin-tazobactam use (p = 0.035) and an earlier onset of MDR infection (p = 0.042). Conclusions: MDR infections were a common complication in critically ill COVID-19 patients at our center. MDR risk was higher among those dwelling longer in the ICU and receiving steroids. However, MDR infections were not associated with a worse outcome.

Effect of Nurse-Led Goal-Directed Lung Physical Therapy on the Prognosis of Pneumonia in Sepsis Patients in the ICU: A Prospective Cohort Study.

Pneumonia poses a significant burden on healthcare systems. However, few studies have focused on nurse-led goal-directed lung physical therapy (GDLPT) for pneumonia in sepsis patients in the intensive care unit (ICU). This study aimed to investigate the effects of nurse-led GDLPT on the prognosis of pneumonia in sepsis patients in the ICU. We performed a prospective 2-phase (before-and-after) study over 3 years. After an observational phase (phase 1, n = 188), we designed, implemented, and evaluated a nurse-led GDLPT protocol (phase 2, n = 359) for pneumonia in sepsis patients in the ICU. The primary outcome was 28-day mortality. We evaluated 742 critically ill patients with sepsis from January 2017 to January 2020. Among the 742 sepsis patients, 609 were diagnosed with pneumonia and 547 who met the inclusion criteria were enrolled in the study. Compared with patients in phase 1, patients in phase 2 had significantly shorter mechanical ventilation duration (5 [4, 6] days vs. 5 [4, 8] days, p = 0.037), shorter ICU stay (9 [4, 16] days vs. 9 [6, 20] days, p = 0.010), lower ICU mortality (15.0% [54/359] vs. 25.5% [48/188], p = 0.003), and lower 28-day mortality (16.7% [60/359] vs. 27.1% ([51/188], p = 0.004). Multivariate logistic regression analysis revealed that nurse-led GDLPT (odds ratio 0.540, 95% confidence interval 0.345-0.846, p = 0.007), clinical pulmonary infection score (odds ratio 1.111, 95% confidence interval 1.012-1.221, p = 0.028), and ventilation day (OR 1.160, 95% CI, 1.058-1.240, p<0.001)were independent predictors of 28-day mortality for pneumonia in sepsis patients, and that nurse-led GDLPT was a protective factor. Nurse-led GDLPT improved the outcomes of pneumonia in sepsis patients, and was particularly associated with shortened mechanical ventilation duration and ICU stay, and reduced ICU mortality and 28-day mortality.

Outcomes of Intensive Care Patients Older Than 90 Years: An 11-Year National Observational Study.

Many intensive care unit (ICU) physicians are reluctant to admit patients aged 90 years and older, although evidence to support these decisions is scarce. Although the body of evidence on outcomes of patients aged 80 years and older is growing, it does not include patients aged 90 years and older. The aim of this study was to compare the short- and long-term mortality of ICU patients aged 90 years and older in the Netherlands with ICU patients aged 80 to 90 years, that is, octogenarians. Multicenter national cohort study over an 11-year period (2008-2018), using data of the National Intensive Care Evaluation (NICE) registry and the Dutch insurance claims registry. All 82 ICUs in the Netherlands. All patients aged 80 years and older at the time of ICU admission. A total of 104,754 patients aged 80 years and older, of whom 9,495 (9%) were 90 years and older, were admitted to Dutch ICUs during the study period. ICU mortality of the patients aged 90 years and older was lower (13.8% vs 16.1%; P < .001) and hospital mortality was similar (26.1% vs 25.7%; P = .41) compared with octogenarians. After 3 months, mortality was higher for the patients aged 90 years and older (43.1% vs 33.7%; P < .001) and after 1-year mortality was 55.0% vs 42.7%; P < .001. In the Netherlands, mortality rates of patients aged 90 years and older admitted to the ICU are not as disappointing as often assumed. They have a lower ICU mortality and a similar hospital mortality compared with octogenarians. Nevertheless, their longer term mortality is higher compared with octogenarians. However, almost 3 of 4 patients leave the hospital alive, and almost half of the patients aged 90 years and older are still alive 1 year after their ICU admission. J Am Geriatr Soc 68:1842-1846, 2020.

Prophylactic noninvasive positive pressure ventilation in the weaning of difficult-weaning tracheotomy patients.

BackgroundProphylactic noninvasive positive pressure ventilation (NPPV) reduces reintubation in endotracheal intubation patients. However, the efficacy of using the prophylactic NPPV in the weaning of tracheotomy patients is unclear.MethodsWe performed prophylactic NPPV in 11 tracheotomy patients who passed a spontaneous breathing trial (SBT), removed the tracheotomy tube, and closed the incision (intervention group). We matched another 11 tracheotomy patients who also passed an SBT but weaning and removing of tracheotomy tube were managed as conventional methods (control group).ResultsPatients in the control group had reinstitution of mechanical ventilation 36 times after the initial SBT success. Compared with the control group, the interventional group had fewer weaning days (3.0±2.1 vs. 11.3±9.2, P=0.01) from initial SBT success to successful weaning and shorter intensive care unit (ICU) length of stay (11.6±4.2 vs. 20.3±11.6, P=0.03) after initial SBT success. The interventional group had lower nosocomial pneumonia rates after initial SBT success (0/11 vs. 2/11), lower ICU mortality (0/11 vs. 2/11), lower hospital mortality (0/11 vs. 3/11), and higher successful weaning rate (11/11 vs. 8/11), but it didn’t reach significant difference. Also, there was no significant difference between groups in total duration of ventilation (25.5±13.3 vs. 34.7±24.2 days), hospital stay after initial SBT success (24.0±22.3 vs. 37.4±31.3 days), total ICU stay (35.7±15.3 vs. 45.0±29.5 days), and total hospital stay (48.7±33.1 vs. 68.6±52.6 days).ConclusionsProphylactic NPPV may be useful to accelerate weaning, and shorten ICU stay after initial SBT success in tracheotomy patients.

Impact of an early mobilization protocol on outcomes in trauma patients admitted to the intensive care unit: A retrospective pre-post study.

Prolonged immobility has detrimental consequences for critically ill patients admitted to the intensive care unit (ICU). Previous work has shown that early mobilization of ICU patients is a safe, feasible and effective strategy to improve outcomes; however, few of these studies focused on trauma ICU patients. Our objective was to assess the impact of implementing an ICU early mobilization protocol (EMP) on trauma outcomes. We conducted a retrospective pre-post study of adult trauma patients (>18 years old) admitted to ICU at a Level I trauma center over a 2-year period prior to and following EMP implementation, allowing for a 1-year transition period. Data were collected from the Nova Scotia Trauma Registry. We compared outcomes (mortality, length of stay [LOS], ventilator-free days) between patients admitted during pre-EMP and post-EMP periods, and assessed for factors associated with outcomes using binary logistic regression and generalized linear models. Overall, 526 patients were included in the analysis (292 pre-EMP, 234 post-EMP). Ages ranged from 18 years to 92 years (mean, 49.0 ± 20.4 years) and 74.3% were men. The post-EMP group had lower ICU mortality (21.6% vs. 12.8%; p = 0.009) and in-hospital mortality (25.3% vs. 17.5%; p = 0.031). After controlling for confounders, patients in the post-EMP group were less likely to die in the ICU (odds ratio, 0.43; 95% confidence interval, 0.24-0.79; p = 0.006) or in-hospital (odds ratio, 0.55; 95% confidence interval; 0.32-0.94; p = 0.03). In-hospital LOS, ICU LOS, ICU-free days, and number of ventilator-free days were similar between the two groups. Trauma patients admitted to ICU during the post-EMP period had decreased odds of ICU mortality and in-hospital mortality. This is the first study to demonstrate a significant reduction in trauma mortality following implementation of an ICU mobility protocol. Therapeutic, level III.

Impact of critical care response team implementation on oncology patient outcomes: A retrospective cohort study.

Introduction:The main goal of a critical care response team (CCRT) is to quickly assess and transfer, if required, rapidly deteriorating patients to an intensive care unit (ICU) to prevent cardiopulmonary arrest, stabilize patients' condition, and help in optimizing the care provided by the primary team. The objective of this study was to investigate the correlation between early intervention by CCRT and the outcome of oncology patients.Materials and Methods:This is a retrospective cohort study conducted at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. KAMC is a tertiary care facility with 1200-bed capacity. The study compared oncology patients to nononcology patients.Results:Over 4 years, a total number of 4941 patients were reviewed, of which 172 were oncology patients. The average age of patients in the oncology group was 48.8 ± 20.7, while the average age for nononcology was 52.8 ± 21.2 (P = 0.016). The average Acute Physiology and Chronic Health Evaluation II score on admission for oncology patients was higher than that for the nononcology group (27.8 ± 8.9 vs. 23.6 ± 9.3, respectively). Lower ICU mortality was seen after CCRT implementation (38.8% vs. 62.7%). The average duration of hospital stay and ICU stay increased after CCRT implementation (37.34 vs. 29.31 and 11.93 vs. 8.9, respectively).Conclusion:In this study, we identified that early intervention by implementing CCRT had a significant impact in reducing ICU mortality for oncology and nononcology patients.

Ascorbic Acid, Thiamine, and Steroids in Septic Shock: Propensity Matched Analysis.

We aimed to study the use of ascorbic acid, thiamine, and steroids (ATS) in patients with septic shock (SS). Data on 62 patients with SS were collected from Acute Physiologic and Chronic Health Evaluation (APACHE) Outcome database and medical records. The ATS group received full doses of intravenous (IV) ATS (ascorbic acid [1.5 g every 6 hours for 4 days], hydrocortisone [50 mg every 6 hours for 7 days], and thiamine [200 mg every 12 hours for 4 days]). Data included age, gender, APACHE III, acute physiologic score (APS), mechanical ventilation (MV), lactic acid (LA), serum creatinine (Cr), duration of vasopressors (VP, days, median: interquartile ranges [IQR]: [Q1, Q3]), MV-free days (median: IQR [Q1-Q3]), percentage of patients requiring renal replacement therapy (RRT) for acute kidney injury (AKI), and mortality. Propensity analysis was used to match patients on age, gender, MV, APACHE III, APS, LA, and Cr. The ATS group had longer duration of VP (4.5: 4.0-6.0 vs 2.0: 1.0-2.0, P = .001), similar RRT for AKI (26% vs 29%, P = .8), similar MV-free days (10.2: 5.0-15.0 vs 10.2: 1.6-18.0, P > .9), lower intensive care unit mortality (9.6% vs 42%, P = .004), and a trend toward lower hospital mortality (29% vs 45%, P = .2) compared to the NO ATS group. The use of IV ascorbic acid, thiamine, and hydrocortisone might be beneficial in patients with SS.

Oseltamivir Therapy Improves Survival in Critically Ill Patients with Severe Influenza

Background: We aimed to determine whether treatment with oseltamivir was associated with decreased mortality among patients admitted to intensive care units (ICUs) with severe influenza and whether early therapy (within 48 hours of symptoms onset) was associated with improved survival rates. Methods: This was a prospective observational study of patients with confirmed influenza who were admitted to 184 ICUs in Spain. The primary outcomes were to investigate the association of ICU mortality with oseltamivir therapy by comparing patients who are untreated (UT group) with those who are treated (all treated; AT group) and those in early treatment (ET) and late treatment (LT) groups. We also assessed the associations of both ET and LT with ICU mortality and compared the results. Findings: We enrolled 4,175 patients of whom 3,537 met the inclusion criteria. Most patients were diagnosed with influenza pneumonia (84·7%). When comparing the AT (n=3,439) and UT (n=98) groups, the former had higher survival after adjusting for severity and confounding factors (Hazard ratio [HR] 0·67; p=0·03). We included 3,388 patients to compare the ET and LT groups. In the multivariable analysis, ICU mortality was lower in the ET group, having an odds ratio of 0·7 (p=0·004). When propensity score matching was applied to a matched cohort (ET, n=790; LT, n=2,522), the ET group had lower ICU mortality (HR 0·78; p=0·008) compared with the LT group, even after a competing risks analysis (sub-HR 0·79; p=0·01). Interpretation: Oseltamivir treatment is associated with better survival rates in patients admitted to ICU with severe influenza, especially when initiated within 48 hours of illness onset. Funding Statement: SEMICYUC (Spanish Society of Critical Care) and Ricardo Barri Casanovas Foundation. Declaration of Interests: JSN-V-T has received research funding from F. Hoffman-La Roche for separate work. He is currently seconded to the Department of Health and Social Care, England (DHSC). The views expressed in this paper are those of the authors and not necessarily those of DHSC. CG-V has received the INTENSIFICACIO Grant- a grant supported by the Catalan Health Agency [PERIS (Pla estrategic de recerca i innovacio en salut – ‘Strategic Plan for Research and Innovation in HealthCare’)]. All other authors declare no competing interests. Ethics Approval Statement: The study was approved by the Joan XXIII University Hospital Ethics Committee (IRB#11809). All data were anonymised, allowing the requirement for informed consent to be waived.