Lower 30-day Mortality Research Articles

Continuous renal replacement therapy with adsorbing filter oXiris in the treatment of sepsis associated acute kidney injury: a single-center retrospective observational study

Background and objectiveCritical bedside ultrasound is widely used in clinical practice, and it can monitor renal perfusion. The reduction of renal perfusion and inflammatory injury are two contributing factors to sepsis-associated acute kidney injury (SA-AKI).The aim of this study was to examine whether the oXiris filter was useful in the continuous renal replacement therapy(CRRT) treatment of SA-AKI patients.Design, setting, participants, and measurementsWe performed a retrospective single-center observational study and enrolled two hundred and forty-three SA-AKI patients from January 2022 to December 2023, who were divided into the oXiris group (n = 88) and the control group (n = 155). The primary endpoints were the 28-day recovery of renal function and 28-day all-cause mortality. The secondary endpoints included renal Doppler markers (RRI, RVSI, and PDU), SOFA, vasoactive-inotropic score (VIS), inflammatory markers (PCT, CRP, IL-10 and TNFα), lactate level, and length of stay in ICU and hospital.ResultsFor the primary endpoint, the rates of complete recovery, partial recovery, and dialysis dependence were observed to be 60.3%, 13.6%, and 26.1% in the oXiris group, respectively, compared to 63.9%, 15.5%, and 20.6% in the control group. The 28-day all-cause mortality was not different in the two groups (22.7% vs. 27.1%). For the secondary endpoint, the oXiris group exhibited greater reductions in VIS scores compared to the control group within the first 24 h (p = 0.001) and 48 h (p < 0.001) of CRRT. Following 48-h of CRRT, lactate levels in the oXiris group were significantly lower than those in the control group (p = 0.014). Prior to CRRT, levels of IL-6 were higher in the oXiris group (p = 0.036), but these differences were not significant after CRRT (p > 0.05). The levels of RRI at T1 (p = 0.002) and T2 (p = 0.001) were lower in the oXiris group than in the control group. Even after adjusting for AKI stage, multivariable Cox regression analysis showed that SOFA and inflammatory factors (TNFα, IL-10, and IL-6), oXiris were significantly associated with a lower 28-day mortality among SA-AKI patients when compared to M150 [HR = 0.466, 95%CI 0.233–0.934, p = 0.031].ConclusionOur findings suggest that the use of the oXiris filter in CRRT is associated with reduced inflammatory injury and improvement in renal perfusion. However, it is not associated with improved 28-day recovery of renal function and 28-day all-cause mortality.

Ramelteon exposure and survival of critically Ill sepsis patients: a retrospective study from MIMIC-IV

BackgroundThe effect of ramelteon, a melatonin receptor agonist, on survival in septic patients remains unknown. The purpose of this retrospective cohort study was to explore the relationship between ramelteon exposure and survival outcomes in septic patients.MethodsData from septic patients admitted to the intensive care unit (ICU) were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, with patients categorized into ramelteon exposure and non-exposure groups based on the use of ramelteon. The primary outcome was 30-day mortality, and secondary outcomes included 90-day mortality, in-hospital mortality, length of ICU stay, and hospital stay. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were employed to address confounding variables. Kaplan–Meier (K-M) analysis and Cox proportional hazards regression models for stepwise regression were utilized to assess the impact of ramelteon exposure on survival.ResultsThis study included 22,152 unexposed patients and 2,708 exposed patients, resulting in 2,607 matched pairs after PSM. Following PSM, ramelteon exposure was associated with significantly lower in-hospital mortality (11.6% vs.19.7%, p < 0.001), 30-day mortality (13.4% vs. 23.2%, p < 0.001), and 90-day mortality (22.1% vs. 30%, p < 0.001).K-M curves demonstrated a significant difference in 30-day and 90-day mortality between the two groups (P < 0.001), irrespective of PSM application. Both PSM (hazard ratio [HR] = 0.53, 95% confidence intervals [CIs] 0.47–0.61, p < 0.001) and IPTW models (HR = 0.59, 95% CI 0.50–0.70, p < 0.001) indicated a significant positive effect of ramelteon usage on 30-day mortality among septic patients compared to the non-exposure group.ConclusionsThis exploratory, retrospective study suggests an association between ramelteon exposure and reduced 30-day and 90-day mortality in septic patients compared with the non-exposure group. Considering the limitations of the retrospective design and the potential for unmeasured confounding, well-designed prospective studies and randomized controlled trials will be needed to confirm these findings.

Management of Severe Pyogenic Spinal Infections: The 2SICK Study by the EANS Spine Section.

Spondylodiscitis management presents significant clinical challenges, particularly in critically ill patients, where the risks and benefits of surgical intervention must be carefully balanced. The optimal timing of surgery in this context remains a subject of debate. This study aims to evaluate the effectiveness of early surgery versus delayed surgery or conservative management in critically ill patients with de novo pyogenic spondylodiscitis. This is an international, multicenter retrospective cohort study involving 24 centers, primarily in Europe. The study included 192 critically ill patients (65.63% male) with a median age of 69 years, all severely affected by pyogenic spondylodiscitis characterized by an initial CRP level >200 mg/l or the presence of two out of four Systemic Inflammatory Response Syndrome criteria upon admission. The primary outcome was 30-day mortality. Secondary outcomes included length of ICU stay, length of hospital stay, and relapse rates of spondylodiscitis. Patients were divided into three groups: early surgery (within three days of admission), delayed surgery (after three days of admission), and conservative therapy. Propensity score matching and multivariate regression analyses were performed to adjust for baseline differences and assess the impact of treatment modalities on mortality and other clinical outcomes. Delayed surgery was associated with significantly lower 30-day mortality (4.05%) compared to early surgery (27.85%) and conservative therapy (27.78%) (p<0.001). Delayed surgery also resulted in shorter hospital stays (42.76 days) compared to conservative therapy (55.53 days) and early surgery (26.33 days) (p<0.001), and shorter ICU stays (4.52 days) compared to conservative therapy (16.48 days) and early surgery (7.92 days) (p<0.001). The optimal window for surgery, minimizing mortality, was identified as ten to fourteen days post-admission (p=0.02). Risk factors for increased mortality included age (p<0.05), multiple organ failure (p<0.05), and vertebral body destruction (p<0.05), whereas delayed surgery (p<0.05) and the presence of an epidural abscess were associated with reduced mortality (p<0.05). Delayed surgery, optimally between 10 to 14 days post-admission, was associated with lower mortality in critically ill spondylodiscitis patients. These findings highlight the potential benefits of considering surgical timing to improve patient outcomes.

Association Between Impella Device Type and Short-Term Prognosis in Patients with Acute Myocardial Infarction-Related Cardiogenic Shock Receiving ECPELLA Support.

The prognosis in patients with acute myocardial infarction-related cardiogenic shock (AMI-CS) remains unsatisfactory even in the era of Impella, especially among the patients who receive concomitant veno-arterial extracorporeal membrane oxygenation (ECMO) support (i.e., ECPELLA). The prognostic impact of Impella device type in patients with AMI-CS receiving ECPELLA support remains uncertain.Patients with AMI-CS who had received Impella-incorporated temporary mechanical circulatory support between 2020 and 2022 were prospectively registered in the Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD). The prognostic impact of Impella device type on the 30-day mortality in patients receiving ECPELLA therapy was retrospectively investigated.A total of 996 patients receiving ECPELLA therapy (median 69 years; out-of-hospital cardiac arrest 36.8%; lactate 8.2 mmol/L) were included. The device type of Impella 5.0/5.5 (n = 73) was associated with a lower 30-day mortality with an adjusted hazard ratio of 0.575 (95% confidence interval 0.369-0.895, P = 0.0143) and a lower 30-day cumulative mortality (35.6% versus 56.8%, P = 0.0002) compared with the Impella 2.5/CP (n = 923).Among the patients with AMI-CS receiving ECPELLA support, Impella 5.0/5.5 use was significantly associated with a lower 30-day mortality compared with smaller Impella devices. Implementing an Impella 5.5 or Impella upgrade from CP to 5.5 may improve the short-term prognosis in patients with advanced AMI-CS who are receiving ECPELLA support.

Mid-term outcome and quality of life after Bentall procedure: single-center experience

The aim – to evaluate the mid-term results and quality of life of patients who underwent Bentall procedure.Materials and methods. The research included 55 patients who underwent planned surgical treatment at the Heart Institute of Ministry of Health of Ukraine from 2015 to 2023. The mean age of the 55 patients (53 (96.36 %) males), who underwent the Bentall procedure (composite graft replacement of the aortic root), was 52.36 ± 1.56 years. We analyzed basic characteristics of the patients, intraoperative and postoperative data. The quality of life was assessed before and in the mid-term period after operations by the Medical Outcomes Study Short Form 36 (MOS SF-36) questionnaire.Results. An average duration of the follow-up period was (3.61 ± 0.28) (СІ 3.05–4.16) years ranging from 1.0 to 9.0 years. Overall, in-hospital mortality and 30-day mortality was 1.89 % (n = 1). The only case of death was caused by the acute respiratory distress syndrome. The 5-year survival rate was 94.61 ± 3.10 % for all patients. It is reasonable to say that all 3 cases of death were due to a non-cardiac cause, i.e. stroke, malignancy and acute abdomen. The average duration of the operations was 244.48 ± 7.67 minutes, the total duration of artificial blood circulation was 138.73 ± 6.47 minutes, aorta clamping time – 95.82 ± 4.79 minutes. The mean duration of hospital staying was 16.98 ± 0.91 days, intensive care unit – 4.84 ± 0.33 days. The number of patients extubated up to 8 hours after surgery was 41 (74.55 %) patients. The operation significantly improved parameters of the quality of life. Conclusions. Patients after Bentall procedure have low overall in-hospital mortality and 30-day mortality (1 (1.89 %)). The 5-year survival rate was 94.61 ± 3.10 %. All three case of death during follow-up period were due to non-cardiac causes. Excellent mid-term results prove that Bentall procedure must be a routine surgery for patients with aortic root aneurysm, mixed aortic valve pathology and anatomically altered aortic valve leaflets. The operation significantly improved quality of life of patients in all domains.

The Association Between Body Mass Index and 28-day Mortality in Patients With Sepsis: A Retrospective Cohort Study.

Sepsis is a severe clinical syndrome with high morbidity and mortality in intensive care units (ICUs). Body Mass Index (BMI) shows a rising trend of obese patients being admitted to ICUs. The relationship between BMI and the clinical outcome of sepsis remains highly debated. The data used in this study were sourced from the Intensive Care Information Center IV (MIMIC-IV) database. Baseline information extracted within 24 hours of ICU admission was categorized according to World Health Organization (WHO)'s BMI classifications. A multivariate Cox regression model and curve fitting assessed the independent correlation between BMI and the primary outcome. A total of 7836 patients were included in the study and categorized into five groups based on BMI. The overall 28-day mortality rate was 21.94% (1719/7836). Class I obesity (17.14%) and class II/III obesity (13.49%) individuals tended to be younger and male. Compared to patients with normal BMI (32.55%), those with low BMI (5.79%) had a 47% increased risk of 28-day mortality (HR 1.47, 95% CI 1.16-1.85, P = 0.0013), while class II/III obesity patients had a 17% lower 28-day mortality rate (HR 0.83, 95% CI 0.71-0.97, P = 0.0218). Curve fitting revealed a nonlinear relationship between BMI and 28-day mortality. The Kaplan-Meier survival analysis highlighted variations in survival rates across the five groups (P = 0.0123), with underweight patients exhibiting poorer survival outcomes. In sepsis patients, a low BMI is related to higher 28-day mortality compared to those with a normal BMI. Conversely, patients with a BMI≥35kg/m2 have significantly reduced mortality risks.

Improving acute care outcome in internal medicine: the role of early stabilization and intermediate care unit.

The progressive reduction of acute care beds will necessitate hospital admission in medical settings solely for acutely ill patients requiring urgent organ support. Early stabilization of the acute condition, potentially through an appropriate treatment unit, may not only improve short-term patient outcomes but also reduce the length of hospital stay. To determine if stabilization of the acute condition in an intermediate care unit (IMCU) is associated with improved patient outcomes and reduced in-hospital stay. A prospective exploratory pilot observational study was conducted at the Department of Internal Medicine of the Alto Vicentino Hospital (Italy), including all patients admitted for non-intensive acute conditions between September and December 2022. The primary endpoint of the study was stabilization of the acute condition within 72h of admission. Three hundred twenty four patients were enrolled. 73.5% (238/324) of patients achieved stabilization at 72h, compared to 26.5% (86/324) who did not achieve stabilization. Among the variables found to be significant in the multivariate analysis, admission to the IMCU was associated with achieving stabilization within 72h with an odds ratio of 2.28 (95% CI 1.29-4.01, p < 0.004). Meanwhile, for 30-day mortality, patient stabilization was found to be protective with an odds ratio of 0.11 (95% CI 0.04-0.29, p < 0.001). Early stabilization is associated with lower 30-day mortality and shorter lengths of stay. Treatment in an IMCU shows higher rates of 72-h stabilization.

Clinical stage IA non-small cell lung cancer with occult pathologic N1 and N2 disease after segmentectomy: does a completion lobectomy justify?

When final pathology shows pathologic N1 or N2 disease after a pulmonary segmentectomy for early stage non-small cell lung cancer (NSCLC), completion of lobectomy could be considered and recommended as an option for treatment. We explored outcomes after segmentectomy for clinical stage IA NSCLC with occult pN1 or pN2 disease. We identified clinical stage IA NSCLC undergoing segmentectomy or lobectomy from the National Cancer Database (NCDB) between 2010 and 2020. We categorized patients by pathologic N diseases (pN0/pN1/pN2). We compared segmentectomy to lobectomy adjusting for patient and clinical characteristics. We explored survival using time-varied Cox regression, 30-day, 90-day mortality, and unplanned 30-day readmission using logistic regression, and length-of-stay using Poisson regression. Of 123,085 clinical IA NSCLC, 7.9% underwent segmentectomy. Pathology showed 2.8% pN1 and 1.9% pN2 after segmentectomy, and 6.5% pN1 and 3.7% pN2 after lobectomy. For pN1, segmentectomy conferred 33% better survival within 2 years (aHR = 0.67, p = 0.03), but similar survival after 2 years (aHR = 1.06, p = 0.7). For pN2, segmentectomy had similar survival with lobectomy (aHR = 0.96, p = 0.7). For all clinical IA NSCLC, segmentectomy was associated with lower 30-day mortality (aOR = 0.55, p < 0.001), 90-day mortality (aOR = 0.57, p < 0.001), readmission (aOR = 0.86, p = 0.01), and shorter length-of-stay (aRR = 0.76, p < 0.001) than lobectomy. Outcomes after segmentectomy for clinical stage IA NSCLC may be associated with better short-term mortality, readmission rate and length-of-stay. Survival with occult pN1 and pN2 after segmentectomy are at least equivalent to lobectomy in completely resected clinical stage IA patients. A completion lobectomy may not be needed after pN1 and N2 findings after the permanent pathology was released.

Abstract 4145845: The Impacts of Albumin Levels on Clinical Outcomes in Patients in the Coronary Care Unit

Background: Hypoalbuminemia is frequently observed in critically ill patients, yet its significance regarding short-term mortality among these patients remains uncertain. We aimed to investigate the impact of albumin levels and their changes on clinical outcomes among patients who were admitted to intensive care units due to cardiac causes. Methods: This is a retrospective, single-center, cohort study. Consecutive patients admitted to coronary care unit (CCU) were enrolled between January 2011 and December 2020. Serum albumin levels were obtained upon CCU admission and tracked for changes. Clinical outcomes were defined as 30-day mortality. Results: A total of 4,004 patients were enrolled. Among them, 1,129 (28.2%) had acute coronary syndrome, 1,915 (47.8%) had coronary artery disease, 1,039 (25.9%) had arrhythmia, and 1,825 (45.6%) had heart failure. There were 643 deaths and 3,361 survivors within 30 days. When comparing to survivors, those who died within 30 days had lower initial albumin levels (3.2 ± 0.9 vs. 3.4 ± 0.8, P &lt; 0.001) and albumin level reduction (-0.1 ± 0.9 vs. 0.0 ± 0.9, P = 0.005). Cox regression multivariate analysis indicated that higher initial albumin levels (HR, 0.638; 95% CI, 0.538 – 0.756, P &lt; 0.001) and increase in albumin levels (HR, 0.638; 95% CI, 0.541 – 0.752, P &lt; 0.001) were independently associated with lower 30-day mortality rates. Conclusions: Higher initial albumin levels and increase in albumin levels were linked to better clinical outcomes in patients admitted to CCU.

Abstract 4115399: Comparative Outcomes of Local-Regional Versus General Anesthesia in Endovascular Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis

Background: Endovascular Aortic Aneurysm Repair (EVAR) has emerged as a less invasive approach to aneurysm repair. However, the optimal anesthesia modality for elective cases—general or local-regional—remains uncertain. This meta-analysis compares the outcomes of local-regional versus general anesthesia (GA) for abdominal EVAR. Methods: We searched MEDLINE, Embase, and Cochrane databases for studies comparing local-regional and general anesthesia for EVAR up to May 2024. Following the PRISMA protocol, 1,796 articles were screened. Endpoints included 30-day mortality, type I endoleaks, length of hospital stay (LHS), and Intensive Care Unit (ICU) admissions. A random-effects model with odds ratios (OR) and 95% confidence intervals (CI) was used for binary endpoints and mean difference (MD) for continuous endpoints. Heterogeneity was assessed using Q and I2 statistics. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach evaluated the quality of evidence. Results: Sixteen cohort studies, encompassing 70,654 patients treated with EVAR after excluding overlapping populations, were included. All groups had similar demographics, American Society of Anesthesiologists physical status, and aneurysm type. The mean age was 73.6 years, and 88.1% were male. Local-regional anesthesia was associated with significantly lower 30-day all-cause mortality (OR 0.74; 95% CI 0.55 to 0.99; p=0.049; I2=0, Figure A), shorter LHS (MD -0.72 days; 95% CI -1.29 to -0.15; p=0.01; I2=87%), and less ICU admissions (OR 0.53; 95% CI 0.31 to 0.93; p=0.027; I2=98%). There was no increase in endoleaks in the local-regional group (OR 0.78; 95% CI 0.55 to 1.09; p=0.143; I2=29%, Figure B). The GRADE rated this evidence as moderate certainty and high importance. Conclusion: Local-regional anesthesia may be preferable to general anesthesia for EVAR, as it reduces 30-day mortality, ICU admissions, and hospital stay length without increasing the risk of type I endoleaks.

Final diagnoses and mortality rates in ambulance patients administered nebulized β2-agonists bronchodilators.

To assess final diagnoses and mortality rates (30day and 1year) in patients treated with the inhaled bronchodilator salbutamol by ambulance personnel, and to establish its role as an identifier of moderate to severe respiratory distress in the prehospital phase of treatment. In a descriptive retrospective observational study, patients experiencing respiratory distress and treated with inhaled bronchodilators, specifically salbutamol, in the prehospital setting within the Central Denmark Region during 2018-2019 were included. The study included 6318 ambulance transports, comprising 3686 cases of acute exacerbation of chronic obstructive pulmonary disease (AECOPD), 234 with community-acquired pneumonia (CAP), 320 with heart disease (HD), 233 adults with asthma, 1674 with various other primary ICD-10 diagnoses (other ≥ 18years), and 171 patients under 18years. The 30day mortality rate for all patients was 10.7% (95% CI 9.8-11.6), with zero deaths within 30days among adults with asthma and those under 18. Excluding low mortality groups, AECOPD patients had the lowest 30day mortality at 10.2% (95% CI 9.1-11.3), and HD patients the highest at 15.3% (95% CI 10.6-19.9). The 1-year overall mortality rate increased to 32.1% (95% CI 30.2-34.0), with mortality staying low for asthma and under-18 groups, while differences between other groups lessened and became insignificant. Patients requiring inhaled bronchodilator treatment in ambulances exhibit notably high mortality rates at 30days and 1year, except for those with asthma or under 18. The need for prehospital bronchodilators could serve as a clear and unmistakable marker for moderate to severe respiratory distress, enabling early intervention.

Chest computed tomography-based artificial intelligence-aided latent class analysis for diagnosis of severe pneumonia.

There is little literature describing the artificial intelligence (AI)-aided diagnosis of severe pneumonia (SP) subphenotypes and the association of the subphenotypes with the ventilatory treatment efficacy. The aim of our study is to illustrate whether clinical and biological heterogeneity, such as ventilation and gas-exchange, exists among patients with SP using chest computed tomography (CT)-based AI-aided latent class analysis (LCA). This retrospective study included 413 patients hospitalized at Xinhua hospital diagnosed with SP from June 1, 2015 to May 30, 2020. AI quantification results of chest CT and their combination with additional clinical variables were used to develop LCA models in an SP population. The optimal subphenotypes were determined though evaluating statistical indicators of all the LCA models, and clinical implications of them such as guiding ventilation strategies were further explored by statistical methods. The two-class LCA model based on AI quantification results of chest CT can describe the biological characteristics of the SP population well and hence yielded the two clinical subphenotypes. Patients with subphenotype-1 had milder infections (P <0.001) than patients with subphenotype-2 and had lower 30-day (P <0.001) and 90-day (P <0.001) mortality, and lower in-hospital (P=0.001) and 2-year (P <0.001) mortality. Patients with subphenotype-1 showed a better match between the percentage of non-infected lung volume (used to quantify ventilation) and oxygen saturation (used to reflect gas exchange), compared with patients with subphenotype-2. There were significant differences in the matching degree of lung ventilation and gas exchange between the two subphenotypes (P<0.001). Compared with patients with subphenotype-2, those with subphenotype-1 showed a relatively better match between CT-based AI metrics of the non-infected region and oxygenation, and their clinical outcomes were effectively improved after receiving invasive ventilation treatment. A two-class LCA model based on AI quantification results of chest CT in the SP population particularly revealed clinical heterogeneity of lung function. Identifying the degree of match between ventilation and gas-exchange may help guide decisions about assisted ventilation.

Cefiderocol Versus Best Available Therapy in the Treatment of Critically Ill Patients with Severe Infections Due to Resistant Gram-Negative Bacteria: A Systematic Review and Meta-Analysis.

This study aims to assess the effectiveness and safety of cefiderocol in treating severe infections caused by multidrug-resistant Gram-negative bacteria (MDR-GNB) in critically ill patients, particularly those in intensive care units (ICUs). A meta-analysis of studies, including randomized clinical trials and observational studies in adult patients, was performed. Studies with at least 50% of critically ill patients were included. Studies with small sample size or without comparison groups were excluded. Sources included PubMed, Scopus, or Google Scholar, up to 14 August 2024. Risk of bias was assessed according to the Cochrane tool. The main outcome examined was 30-day mortality, while secondary outcomes assessed included clinical cure rates and adverse effects. Results were expressed with odds ratios. No funding was received for this study. It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with reference CRD42024563041. eight studies, with 1339 patients were included in the meta-analysis. Cefiderocol treatment was associated with a lower 30-day mortality rate than other available therapies (pooled OR 0.47; 95% CI: 0.23-0.97, p = 0.04), particularly in cases of carbapenem-resistant A. baumannii infections (pooled OR 0.29; 95% CI: 0.14-0.60, p < 0.001). Although there was a non-significant trend toward higher clinical cure rates in the cefiderocol group (OR 1.59; 95% CI: 0.96-2.62, p = 0.07), the drug demonstrated at least non-inferiority when compared to other treatment options. Study limitations included moderate heterogeneity between studies, and a high risk of bias in non-RCT studies. (Five cohort studies were included). Another limitation is that five of the eight studies compared cefiderocol versus colistine, an antibiotic with known toxicity. The findings suggest that cefiderocol is a promising therapeutic option for managing severe MDR-GNB infections in critically ill patients, offering a potential global benefit on mortality and at least non-inferiority in the cure rate when compared with other therapies.

Effect of timing of norepinephrine administration on prognosis of patients with septic shock: A prospective cohort study

BackgroundSepsis and septic shock are major healthcare problems worldwide, associated with substantial mortality. Early administration of norepinephrine in septic shock patients has been associated with an increased survival rate, but the timing from septic shock to norepinephrine initiation is controversial. This study examined the associations between the timing of initial norepinephrine administration and clinical outcomes in adult patients with septic shock. MethodsThis prospective cohort study was conducted from September 2021 to June 2022 in an intensive care unit (ICU) of a tertiary general hospital. All enrolled patients were divided into early and late norepinephrine groups according to whether the time from the onset of septic shock to the first application of norepinephrine was >1 h. The primary outcome was 28-day mortality. Secondary outcomes included ICU length of stay (LOS), hospital LOS, time to achieve a mean arterial pressure (MAP) ≥65 mmHg, 24-h infusion volume, 6-h Lac clearance, mechanical ventilation days, and continuous renal replacement therapy (CRRT )ratio. Multivariable logistic regression analysis was used to evaluate the independent risk factors for 28-day mortality. ResultsThis study enrolled 120 patients, including 42 patients (35.0%) and 78 patients (65.0%) in the early and late norepinephrine groups, respectively. The 28-day mortality was lower in the early group than in the late group (28.6% vs. 47.4%, P=0.045). The median time to achieve MAP ≥65 mmHg was shorter in the early group than in the late group (1 h vs. 1.5 h, P=0.010). The median 24-h intravenous fluids volume in the early group was lower than that in the late group (40.7% vs. 14.9%, P=0.030). The median 6-h lactate (Lac) clearance rate in the early group was higher than that in the late group (40.7% vs. 14.9%, P=0.009). There were no significant differences between early and late groups by ICU LOS (P=0.748), hospital LOS (P=0.369), mechanical ventilation time (P=0.128), and CRRT ratio (P=0.637). The independent risk factors for 28-day mortality included being male (odds ratio [OR]=3.288, 95% confidence interval [CI]: 1.236 to 8.745, P = 0.017), time to norepinephrine initiation >1 h (OR=4.564, 95% CI: 1.382 to 15.079, P = 0.013), and time to achieve MAP ≥65 mmHg (OR=1.800, 95% CI: 1.171 to 2.767, P = 0.007). ConclusionsNorepinephrine initiation ≤1 h is associated with lower 28-day mortality in patients with septic shock. Early norepinephrine administration is also associated with a shorter time to achieve MAP ≥65 mmHg, lower 24-h intravenous fluids volume, and higher 6-h Lac clearance rate. Being male, time to achieve MAP ≥65 mmHg, and norepinephrine initiation >1 h are independent risk factors for 28-day mortality.Trial registration Chinese Clinical Trial Registry Identifier: ChiCTR2100044071.

Preparing for future pandemics: Automated intensive care electronic health record data extraction to accelerate clinical insights

BackgroundManual data abstraction from electronic health records (EHRs) for research on intensive care patients is time-intensive and challenging, especially during high-pressure periods such as pandemics. Automated data extraction is a potential alternative but may raise quality concerns. This study assessed the feasibility and credibility of automated data extraction during the coronavirus disease 2019 (COVID-19) pandemic. MethodsWe retrieved routinely collected data from the COVID-Predict Dutch Data Warehouse, a multicenter database containing the following data on intensive care patients with COVID-19: demographic, medication, laboratory results, and data from monitoring and life support devices. These data were sourced from EHRs using automated data extraction. We used these data to determine indices of wasted ventilation and their prognostic value and compared our findings to a previously published original study that relied on manual data abstraction largely from the same hospitals. ResultsUsing automatically extracted data, we replicated the original study. Among 1515 patients intubated for over 2 days, Harris–Benedict (HB) estimates of dead space fraction increased over time and were higher in non-survivors at each time point: at the start of ventilation (0.70±0.13 vs. 0.67±0.15, P <0.001), day 1 (0.74±0.10 vs. 0.71±0.11, P<0.001), day 2 (0.77±0.09 vs. 0.73±0.11, P<0.001), and day 3 (0.78±0.09 vs. 0.74±0.10, P<0.001). Patients with HB dead space fraction above the median had an increased mortality rate of 13.5%, compared to 10.1% in those with values below the median (P<0.005). Ventilatory ratio showed similar trends, with mortality increasing from 10.8% to 12.9% (P=0.040). Conversely, the end-tidal-to-arterial partial pressure of carbon dioxide (PaCO₂) ratio was inversely related to mortality, with a lower 28-day mortality in the higher than median group (8.5% vs. 15.1%, P<0.001). After adjusting for base risk, impaired ventilation markers showed no significant association with 28-day mortality. ConclusionManual data abstraction from EHRs may be unnecessary for reliable research on intensive care patients, highlighting the feasibility and credibility of automated data extraction as a trustworthy and scalable solution to accelerate clinical insights, especially during future pandemics.

‘Effectiveness of various sulbactam-based combination antibiotic therapy in the management of ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter baumannii in a tertiary care Health centre’

ObjectiveCarbapenem-resistant Acinetobacter baumannii (CRAB) is a common cause of ventilator-associated pneumonia (VAP). Some in vitro data favour various combination antibiotic therapy. However, there is a need for more in vivo studies for the management of VAP caused by CRAB. This retrospective study was done to evaluate the effectiveness of various combination antibiotic therapy including sulbactam on outcomes of VAP caused by CRAB. MethodsAdult patients (age ≥18 years) diagnosed with VAP caused by CRAB were included. Patients with polymicrobial infections were excluded from the study. Patients with CRAB associated VAP who were given sulbactam based antibiotic combinations were observed for outcomes. The primary outcome was 28-day mortality after diagnosis of VAP caused by CRAB. Reduction in serum HsCRP (High sensitivity C-reactive protein) during treatment and requirement of inotropes were the secondary outcomes. Outcomes were compared between various sulbactam based antibiotic combination therapies. ResultsA total of 103 patients were included. A total of 44 (42.7 %) patients received sulbactam and minocycline or sulbactam and polymyxin B dual antibiotic combination, and 59 (57.3 %) patients received sulbactam, polymyxin B and minocycline triple antibiotic combination. The percentage difference in 28 days mortality was 27.51 % (95 % CI 8.03 %–44.06 %; p = 0.005) in dual vs triple sulbactam based antibiotic combination therapy. The percentage difference in requirement of inotropes during therapy and HsCRP reduction after 7 days of therapy was 23.65 % (95 % CI 6.43 %–38.3 %; p = 0.007) and 25.1 % (95%CI 10.1 %–38.2 %; p < 0.001) respectively when compared between dual vs triple sulbactam based antibiotic combination therapy. ConclusionTreatment with sulbactam, polymyxin B and minocycline combination antibiotic therapy was associated with significantly lower 28-day mortality. Moreover, the lower requirement of inotropes during treatment and a significant reduction in HsCRP level favours this combination antibiotic therapy in VAP caused by CRAB.

Associations of interfacility transfer with clinical presentation and early mortality in patients with type a acute aortic dissection: a registry study

Abstract Background Acute aortic dissection (AAD), particularly Stanford type A, is a life-threatening condition with high morbidity and mortality that requires prompt diagnosis and urgent intensive treatment including surgical repair. Our reginal aortic network has been established to develop the effective and safe transfer system for patients with AAD. Purpose This study aimed to assess how interfacility transfer impacts clinical presentation and early mortality in type A AAD patients using multicenter registry data. Methods We studied 1024 consecutive patients (age: 70 [58-79] years, 55% male) who were hospitalized for type A AAD within 24 hours after symptom onset during 2017–2018. Patients with cardiopulmonary arrest before hospital arrival were excluded. Multivariable logistic regression analysis was used to evaluate the association between interfacility transfer and operative mortality. Results In this study cohort, 539 patients were transferred from another facility, whereas the remaining 485 were directly admitted to the presenting hospital. Patients with transfer had a longer time from symptom onset to emergency surgery than those without transfer (326 [267–472] min vs. 282 [216–390] min, p&amp;lt;0.001). AAD-related complications (cardiac tamponade, cardiac arrest, shock, aortic rupture, end-organ malperfusion) were more frequent in patients without transfer (32.0% vs 24.5%, p=0.008). Patients with transfer underwent surgical and/or endovascular treatment more frequently (92.9% vs. 74.8%, p&amp;lt;0.001) and had a lower 30-day mortality rate than those without transfer (7.1% vs. 21.9%, p&amp;lt;0.001). The operative mortality was also lower in patients with transfer than in those without transfer (30/501 [6.0%] vs. 43/363 [11.8%], p=0.002). The multivariable analysis conducted in this study revealed that the presence of AAD-related complications at admission was associated with a higher operative mortality (odds ratio [OR]: 5.10; 95% confidence interval [CI]: 3.00–8.67, p&amp;lt;0.001), whereas interfacility transfer was associated with a lower operative mortality (OR: 0.54; 95% CI:0.31–0.95, p=0.031). Conclusion These findings underscore the critical role of efficient transfer systems and early intervention in managing type A AAD. Despite the delay from symptom onset to surgical intervention, interfacility transfer did not lead to adverse outcomes for patients with type A AAD.

Levosimendan in patients with cardiogenic shock refractory to dobutamine weaning

Abstract Background The role of Levosimendan in managing cardiogenic shock remains the subject of debate. Objective This study examines the use and effects of Levosimendan when combined with dobutamine in patient’s refractory to dobutamine weaning. Methods This retrospective study included patients with cardiogenic shock admitted between January 1st, 2010, and October 31st, 2022. After initial dobutamine weaning failure, we compared patients who were treated with dobutamine alone versus those for whom Levosimendan was added in top of dobutamine. The primary outcome was successful inotrope withdrawal, defined as survival without catecholamine support, transplant, or definitive ventricular assist device at 30 days. Secondary outcomes included all-cause mortality at 30 and 90 days. Data analysis used inverse probability weighting according to propensity score. Results Among 349 patients with cardiogenic shock and failure to withdraw dobutamine, Levosimendan was used on top of dobutamine in 114 patients, and another try of dobutamine alone was made in 235 patients. At 30 days, successful inotrope withdrawal occurred in 46 (43.4%) patients with Levosimendan and dobutamine versus 24 (10.5%) patients of the dobutamine only group (weighted OR 4.99 [2.65 - 9.38]; p&amp;lt;0.001), with similar results at 90 days (weighted OR 6.16 [3.22-11.78]; p&amp;lt;0.001). Levosimendan + dobutamine was associated with lower 30-day mortality (weighted OR 0.47 [0.26-0.84]; p=0.01), with no difference at 90 days (weighted OR= 0.67 [0.39-1.14]; p=0.14). Conclusion Adding Levosimendan to dobutamine may improve inotrope withdrawal success and reduce 30-day mortality in patients with initial weaning failure, especially in those without project of cardiac assistance or transplant.

Clinical impact of helicopter transport with a physician in cardiogenic shock complicating acute coronary syndrome

Abstract Introduction Cardiogenic shock (CS) remains the leading cause of death in patients with acute coronary syndrome (ACS). Helicopter transport with a physician may improve the prognosis through reduction of the ischemic time and an early critical care. However, the impact of transfer of a physician-staffed helicopter and outcomes of CS complicating ACS is uncertain. Purpose The aim of the present study was to evaluate compare the clinical characteristics and long-term outcome between helicopter transport with a physician and ground transport in CS complicating ACS patients. Methods We retrospectively investigated 2324 consecutive patients with ACS who underwent primary percutaneous coronary intervention (pPCI) in our institution from January 2004 to December 2017. The primary outcome was cardiovascular (CV) death. Results Among the 2324 eligible patients, 273 ACS patients (11.7%) were complicated by CS. Of 273 CS complicating ACS, a total of 81 (29.7%) patients were transported by helicopter, 166 (60.8%) patients were transported by ambulance, and 26 (9.5%) patients did not use emergency medical service. The mean age was 71 years, 75% of patients were male, STEMI was seen in 87%, and mechanical circulatory support was used in 64%. Kaplan-Meier analysis showed that CV mortality up to 30 days was significantly lower with helicopter transport group compared those with ground transport (P = 0.0407). The rate of long-term CV death was comparable between groups (P = 0.19). Multivariate Cox regression analysis showed helicopter transport was significantly associated with lower 30-day CV mortality (adjusted HR 0.56, 95%CI 0.32-0.99, P = 0.0447). Conclusions Helicopter transport with a physician may improve cardiovascular outcomes of CS complicating ACS.Figure 1.Figure 2.

Unraveling the paradox: the impact of one or more traditional risk factors on short-term mortality following acute coronary syndromes.

Abstract Background It has been recently suggested that individuals without exposure to any standardized modifiable risk factors may have an increased risk of all-cause mortality from acute coronary syndromes (ACS) compared with their counterparts with one or more risk factors, including diabetes. Purpose To estimate the individual contribution of the four traditional risk factors to the risk of adverse outcomes from first ACS. Methods We analyzed data from 70,953 Caucasian patients presenting with first ACS, but without prior coronary heart disease in the International Survey of Acute Coronary Syndromes (ISACS) Archives registry network from October 2005 to January 2021. The primary outcome was all-cause mortality within 30 days after hospital admission. We calculated sex-specific risk ratios (RRs) stratifying traditional risk factors, current smoking, diabetes, hypercholesterolemia and hypertension into mutually exclusive categories using a balancing strategy by inverse probability weighting. Results Compared with patients presenting without risk factors, those with diabetes had significantly higher 30-day mortality in both women (RR, 1.29; 95% CI, 1.06-1.57) and men (RR, 1.40; 95% CI, 1.16-1.69). By contrast, patients who were current smokers or presented with a history of hypercholesterolemia or hypertension had significantly lower 30-day mortality than patients with no risk factors with RRs ranging from 0.53; 95% CI 0.42–0.67 in women who were smokers to 0.46; 95% CI 0.37–0.59 in men with hypercholesterolemia. The impact of diabetes on mortality was obscured in patients who concomitantly presented with diabetes and one more traditional risk factor. The RRs in combination with current smoking were 1.39; 95% CI 0.92 -2.09 in women and 0.89; 95% CI 0.68 -1.17 in men; with hypercholesterolemia: 0.91; 95% CI 0.66 -1.25 in women and 0.75; 95% CI 0.53–1.06 in men; with hypertension: 1.14; 95% CI 0.99–1.32 in women and 1.12; 95% CI 0.96–1.31 in men. Conclusions Diabetes confers a significant independent excess mortality risk at 30 days following ACS. Dilution bias in this setting refers to the weakening of the observed effect of diabetes because of the inclusion of "one more" risk factor with lower risk profile. Potential misinterpretation of the relationship between diabetes and death from ACS may negatively affect healthcare organization