Mean Sequential Organ Failure Assessment Research Articles

Acetaminophen for Prevention and Treatment of Organ Dysfunction in Critically Ill Patients With Sepsis

Acetaminophen (paracetamol) has many pharmacological effects that might be beneficial in sepsis, including inhibition of cell-free hemoglobin-induced oxidation of lipids and other substrates. To determine whether acetaminophen increases days alive and free of organ dysfunction in sepsis compared with placebo. Phase 2b randomized, double-blind, clinical trial conducted from October 2021 to April 2023 with 90-day follow-up. Adults with sepsis and respiratory or circulatory organ dysfunction were enrolled in the emergency department or intensive care unit of 40 US academic hospitals within 36 hours of presentation. Patients were randomized to 1 g of acetaminophen intravenously every 6 hours or placebo for 5 days. The primary end point was days alive and free of organ support (mechanical ventilation, vasopressors, and kidney replacement therapy) to day 28. Treatment effect modification was evaluated for acetaminophen by prerandomization plasma cell-free hemoglobin level higher than 10 mg/dL. Of 447 patients enrolled (mean age, 64 [SD, 15] years, 51% female, mean Sequential Organ Failure Assessment [SOFA] score, 5.4 [SD, 2.5]), 227 were randomized to acetaminophen and 220 to placebo. Acetaminophen was safe with no difference in liver enzymes, hypotension, or fluid balance between treatment arms. Days alive and free of organ support to day 28 were not meaningfully different for acetaminophen (20.2 days; 95% CI, 18.8 to 21.6) vs placebo (19.6 days; 95% CI, 18.2 to 21.0; P = .56; difference, 0.6; 95% CI, -1.4 to 2.6). Among 15 secondary outcomes, total, respiratory, and coagulation SOFA scores were significantly lower on days 2 through 4 in the acetaminophen arm as was the rate of development of acute respiratory distress syndrome within 7 days (2.2% vs 8.5% acetaminophen vs placebo; P = .01; difference, -6.3; 95% CI, -10.8 to -1.8). There was no significant interaction between cell-free hemoglobin levels and acetaminophen. Intravenous acetaminophen was safe but did not significantly improve days alive and free of organ support in critically ill sepsis patients. ClinicalTrials.gov Identifier: NCT04291508.

SOFA and APACHE II scoring systems for predicting outcome of neurological patients admitted in a tertiary hospital intensive care unit.

The field of neurology encompasses the study and treatment of disorders that affect the nervous system, and patients with neurological conditions often require specialized care, particularly in the ICU. Predictive scoring systems are measures of disease severity used to predict patient outcomes. The aim of this study was to compare the discriminative power of commonly used scoring systems, namely the sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) in the ICU of a tertiary care hospital. This retrospective study included patients with neurological disorders in the ICUs of Tribhuvan University Teaching Hospital from 1 January 2022 to 31 December 2022. A total of 153 patients were included. The mean age of the patients was 54.76 ± 17.32 years with higher male predominance (60.78%). Ischaemic stroke was the most common neurological disorder. There were 58 patients (37.9%) who required mechanical ventilation and all-cause mortality was 20.9%. The mean SOFA score was significantly higher (P=0.002) in survivors, whereas the mean APACHE II did not show a significant difference (P=0.238). Receiver operating characteristic (ROC) analysis showed the area of curve (AUC) of SOFA score was 0.765 and of APACHE II was 0.722. SOFA score had comparatively higher discriminative power than APACHE II. Assessment of the performance of scoring systems in a specific ICU setting improves the sensitivity and applicability of the model to these settings.

Utilizing the National Early Warning Score 2 (NEWS2) to confirm the impact of emergency department management in sepsis patients: a cohort study from taiwan 1998–2020

BackgroundMost sepsis patients could potentially experience advantageous outcomes from targeted medical intervention, such as fluid resuscitation, antibiotic administration, respiratory support, and nursing care, promptly upon arrival at the emergency department (ED). Several scoring systems have been devised to predict hospital outcomes in sepsis patients, including the Sequential Organ Failure Assessment (SOFA) score. In contrast to prior research, our study introduces the novel approach of utilizing the National Early Warning Score 2 (NEWS2) as a means of assessing treatment efficacy and disease progression during an ED stay for sepsis.ObjectivesTo evaluate the sepsis prognosis and effectiveness of treatment administered during ED admission in reducing overall hospital mortality rates resulting from sepsis, as measured by the NEWS2.MethodsThe present investigation was conducted at a medical center from 1997 to 2020. The NEWS2 was calculated for patients with sepsis who were admitted to the ED in a consecutive manner. The computation was based on the initial and final parameters that were obtained during their stay in the ED. The alteration in the NEWS2 from the initial to the final measurements was utilized to evaluate the benefit of ED management to the hospital outcome of sepsis. Univariate and multivariate Cox regression analyses were performed, encompassing all clinically significant variables, to evaluate the adjusted hazard ratio (HR) for total hospital mortality in sepsis patients with reduced severity, measured by NEWS2 score difference, with a 95% confidence interval (adjusted HR with 95% CI). The study employed Kaplan-Meier analysis with a Log-rank test to assess variations in overall hospital mortality rates between two groups: the “improvement (reduced NEWS2)” and “non-improvement (no change or increased NEWS2)” groups.ResultsThe present investigation recruited a cohort of 11,011 individuals who experienced the first occurrence of sepsis as the primary diagnosis while hospitalized. The mean age of the improvement and non-improvement groups were 69.57 (± 16.19) and 68.82 (± 16.63) years, respectively. The mean SOFA score of the improvement and non-improvement groups were of no remarkable difference, 9.7 (± 3.39) and 9.8 (± 3.38) years, respectively. The total hospital mortality for sepsis was 42.92% (4,727/11,011). Following treatment by the prevailing guidelines at that time, a total of 5,598 out of 11,011 patients (50.88%) demonstrated improvement in the NEWS2, while the remaining 5,403 patients (49.12%) did not. The improvement group had a total hospital mortality rate of 38.51%, while the non-improvement group had a higher rate of 47.58%. The non-improvement group exhibited a lower prevalence of comorbidities such as congestive heart failure, cerebral vascular disease, and renal disease. The non-improvement group exhibited a lower Charlson comorbidity index score [4.73 (± 3.34)] compared to the improvement group [4.82 (± 3.38)] The group that underwent improvement exhibited a comparatively lower incidence of septic shock development in contrast to the non-improvement group (51.13% versus 54.34%, P < 0.001). The improvement group saw a total of 2,150 patients, which represents 38.41% of the overall sample size of 5,598, transition from the higher-risk to the medium-risk category. A total of 2,741 individuals, representing 48.96% of the sample size of 5,598 patients, exhibited a reduction in severity score only without risk category alteration. Out of the 5,403 patients (the non-improvement group) included in the study, 78.57% (4,245) demonstrated no alteration in the NEWS2. Conversely, 21.43% (1,158) of patients exhibited an escalation in severity score. The Cox regression analysis demonstrated that the implementation of interventions aimed at reducing the NEWS2 during a patient’s stay in the ED had a significant positive impact on the outcome, as evidenced by the adjusted HRs of 0.889 (95% CI = 0.808, 0.978) and 0.891 (95% CI = 0.810, 0.981), respectively. The results obtained from the Kaplan-Meier analysis indicated that the survival rate of the improvement group was significantly higher than that of the non-improvement group (P < 0.001) in the hospitalization period.ConclusionThe present study demonstrated that 50.88% of sepsis patients obtained improvement in ED, ascertained by means of the NEWS2 scoring system. The practical dynamics of NEWS2 could be utilized to depict such intricacies clearly. The findings also literally supported the importance of ED management in the comprehensive course of sepsis treatment in reducing the total hospital mortality rate.

Neutrophil-to-lymphocyte ratio as marker of organ dysfunction severity in patients with sepsis in the intensive care unit: An observational study

Abstract Background: The neutrophil-to-lymphocyte ratio (NLR) is an easily computable parameter and is believed to accurately determine the disease-related organ dysfunction severity and prognosis in sepsis. Methods: This study aimed at identifying the role of NLR in predicting organ dysfunction severity and prognosis in patients with sepsis requiring admission to an intensive care unit (ICU). In this observational study, NLR and Sequential Organ Failure Assessment (SOFA) scores were calculated at the time of admission in patients with sepsis. Patients were followed until discharge or death. Results: Fifty five ICU patients with sepsis were enrolled. The mean NLR and SOFA scores for the total study cohort were 7.91 ± 3.01 and 8.76 ± 3.16, respectively. The corresponding values for those in septic shock were 8.96 ± 2.80 and 9.94 ± 3.78. A positive correlation was observed between SOFA score and NLR in all patients (r = 0.5584, P &lt; 0.001); patients with sepsis only (r = 0.4821, P = 0.002); and patients with sepsis and shock (r = 0.6321, P = 0.004). In the total population, mean NLR was significantly higher among non-survivors, compared to survivors (9.17±3.1 vs. 7.09±2.7 ; P = 0.0054). Conclusions: NLR at admission shows a good correlation with the organ dysfunction severity in sepsis and may be used as a prognostic marker, thereby guiding the intensification of management.

The association between levosimendan and mortality in patients with sepsis or septic shock: a systematic review and meta-analysis.

Levosimendan is increasingly being used in patients with sepsis or septic shock because of its potential to improve organ function and reduce mortality. We aimed to determine if levosimendan can reduce mortality in patients with sepsis or septic shock via meta-analysis. We comprehensively searched the PubMed, Embase, Web of Science, and Cochrane Library databases from inception through 1 October 2022. Literature evaluating the efficacy of levosimendan in patients with sepsis or septic shock was included. Two reviewers extracted data and assessed study quality. A meta-analysis was performed to calculate an odds ratio (OR), 95% confidence intervals (CI), and P -values for 28-day mortality (primary outcome). Secondary outcomes included changes in indexes reflecting cardiac function before and after treatment, changes in serum lactate levels in the first 24 h of treatment, and the mean SOFA score during the study period. Safety outcomes included rates of tachyarrhythmias and total adverse reactions encountered with levosimendan. Eleven randomized controlled trials were identified, encompassing a total of 1044 patients. After using levosimendan, there was no statistical difference between groups for 28-day mortality (34.9% and 36.2%; OR: 0.93; 95% CI [0.72-1.2]; P = 0.57; I 2 = 0%; trial sequential analysis-adjusted CI [0.6-1.42]) and sequential organ failure assessment (SOFA) score, and more adverse reactions seemed to occur in the levosimendan group, although the septic shock patient's heart function and serum lactate level improved. There was no association between the use of levosimendan and 28-day mortality and SOFA scores in patients with septic shock, though there was statistically significant improvement in cardiac function and serum lactate.

Landiolol and Organ Failure in Patients With Septic Shock

Patients with septic shock undergo adrenergic stress, which affects cardiac, immune, inflammatory, and metabolic pathways. β-Blockade may attenuate the adverse effects of catecholamine exposure and has been associated with reduced mortality. To assess the efficacy and safety of landiolol in patients with tachycardia and established septic shock requiring prolonged (>24 hours) vasopressor support. An open-label, multicenter, randomized trial involving 126 adults (≥18 years) with tachycardia (heart rate ≥95/min) and established septic shock treated for at least 24 hours with continuous norepinephrine (≥0.1 μg/kg/min) in 40 UK National Health Service intensive care units. The trial ran from April 2018 to December 2021, with early termination in December 2021 due to a signal of possible harm. Sixty-three patients were randomized to receive standard care and 63 to receive landiolol infusion. The primary outcome was the mean Sequential Organ Failure Assessment (SOFA) score from randomization through 14 days. Secondary outcomes included mortality at days 28 and 90 and the number of adverse events in each group. The trial was stopped prematurely on the advice of the independent data monitoring committee because it was unlikely to demonstrate benefit and because of possible harm. Of a planned 340 participants, 126 (37%) were enrolled (mean age, 55.6 years [95% CI, 52.7 to 58.5 years]; 58.7% male). The mean (SD) SOFA score in the landiolol group was 8.8 (3.9) compared with 8.1 (3.2) in the standard care group (mean difference [MD], 0.75 [95% CI, -0.49 to 2.0]; P = .24). Mortality at day 28 after randomization in the landiolol group was 37.1% (23 of 62) and 25.4% (16 of 63) in the standard care group (absolute difference, 11.7% [95% CI, -4.4% to 27.8%]; P = .16). Mortality at day 90 after randomization was 43.5% (27 of 62) in the landiolol group and 28.6% (18 of 63) in the standard care group (absolute difference, 15% [95% CI, -1.7% to 31.6%]; P = .08). There were no differences in the number of patients having at least one adverse event. Among patients with septic shock with tachycardia and treated with norepinephrine for more than 24 hours, an infusion of landiolol did not reduce organ failure measured by the SOFA score over 14 days from randomization. These results do not support the use of landiolol for managing tachycardia among patients treated with norepinephrine for established septic shock. EU Clinical Trials Register Eudra CT: 2017-001785-14; isrctn.org Identifier: ISRCTN12600919.

Prognostic Significance of Nucleated RBCs in Predicting Mortality Among ST-Elevation Myocardial Infarction Patients Admitted to the ICU.

Background The nucleated red blood cells (NRBCs) are a readily available hematological parameter with potential for risk stratification for mortality. Therefore, our objective was to assess the predictive significance of NRBCs for ICU mortality among ST-elevation myocardial infarction (STEMI) patients admitted to an ICU. Additionally, we aimed to compare the predictive capacity of NRBCs with that of the acute physiology and chronic health evaluation (APACHE) II score and the sequential organ failure assessment (SOFA) score. Methodology This descriptive cross-sectional study was conducted in the ICU of the National Institute of Cardiovascular Diseases (NICVD) in Karachi, Pakistan, from the 1st of February to the 30th of June, 2023. We included adult patients (≥18 years) diagnosed with STEMI who were subsequently admitted to the ICU. NRBCs were assessed in all patients over up to five days at 24-hour intervals, and the highest NRBC levels were used for the final analysis. Furthermore, the APACHE II score and the SOFA score were also documented. Patients were monitored throughout their ICU stay, and any adverse events or complications, such as re-intubation, bleeding necessitating transfusion, requirement for renal replacement therapy, arrhythmias, re-infarction, and mortality, were recorded. Results This study included 151 patients, of whom 97 (64.2%) were male, with an average age of 61.1 ± 10.7 years. Patients with positive NRBCs had higher mean SOFA scores (7.4 ± 2.9 vs. 5.4 ± 2.6; p < 0.001) and APACHE II scores (14.6 ± 6.3 vs. 12.6 ± 5.5; p = 0.037) compared to those with negative NRBCs. The culprit vessel showed greater mean stenosis (%) in patients with positive NRBCs (98.8 ± 3.0% vs. 96.8 ± 5.7%; p = 0.004). Post-procedure thrombolysis in myocardial infarction (TIMI) flow grade III was lower in patients with positive NRBCs (77.8% vs. 91.8% for positive vs. negative NRBCs, respectively). Moreover, patients with positive NRBCs experienced significantly higher mortality rates (63% vs. 8.2%; p < 0.001), a higher occurrence of arrhythmias (35.2% vs. 19.6%; p = 0.034), and an increased requirement for vasopressors/inotropic support (96.3% vs. 71.1%; p < 0.001) compared to those with negative NRBCs. NRBCs demonstrated superior discriminatory ability compared to the SOFA and APACHE II scores, with an area under the curve of 0.818 (95% CI: 0.738-0.899) for NRBCs, 0.774 (95% CI: 0.692-0.857) for SOFA, and 0.707 (95% CI: 0.613-0.801) for APACHE II. Positive NRBCs exhibited a sensitivity of 81.0% and a specificity of 81.7% in predicting ICU mortality. Conclusion In conclusion, positive NRBCs emerge as a robust and reliable prognostic indicator, strongly associated with an elevated risk of ICU mortality in STEMI patients. Moreover, the predictive power of positive NRBCs surpasses that of both SOFA and APACHE II scoring systems.

Association of Neutrophil-to-lymphocyte Ratio with Prognosis in Sepsis – An Observational Study from a Tertiary Care Center

Abstract Objectives: This study aims to determine the association of neutrophil-lymphocyte ratio (NLR) with sequential organ failure assessment (SOFA) score, ventilator use, duration of intensive care unit (ICU) stay, and mortality among patients with sepsis. Methods: This prospective observational study included 220 patients with sepsis admitted to the ICU. Details such as age, gender, comorbidities, complaints, SOFA score, diagnosis, and outcomes were collected. Routine investigations included complete blood count, C-reactive protein, and procalcitonin. NLR was derived using the Beckman Coulter DXH-800 Hematology Analyser. A cutoff of 9.11 was taken as high NLR. Patients were followed up till 28 days after treatment. The outcomes studied included 28-day mortality and ICU stay. Results: The mean SOFA score were 7.07 ± 2.56. Based on NLR cutoffs, 146 (66.36%) patients had high NLR while 74 (33.64%) cases had normal or low NLR. SOFA score showed no significant association with high NLR (P = 0.62). Ventilator was used in 118 (53.6%) cases with median of 3.5 days’ duration. The overall ICU stay was 5.6 ± 4.9 days. Mortality was seen in 46 (20.9%) cases. Compared to those with normal NLR, patients with high NLR had significantly more ventilator use (60.9% vs. 39.1%, P = 0.0027) and mortality (30.14% vs. 2.7%, P = 0.0004). The duration of ventilator use and ICU stay was statistically comparable. Conclusion: High NLR shows a significant association with adverse outcomes of sepsis patients in terms of ventilator use and mortality. Since it is cheap and easy to use, it can be applied in more basic settings while monitoring sepsis patients.

Rapid implementation of an emergency on-site CKRT dialysate production system during the COVID-19 pandemic

BackgroundOn December 29, 2021, during the delta wave of the Coronavirus Disease 2019 (COVID-19) pandemic, the stock of premanufactured solutions used for continuous kidney replacement therapy (CKRT) at the University of New Mexico Hospital (UNMH) was nearly exhausted with no resupply anticipated due to supply chain disruptions. Within hours, a backup plan, devised and tested 18 months prior, to locally produce CKRT dialysate was implemented. This report describes the emergency implementation and outcomes of this on-site CKRT dialysate production system.MethodsThis is a single-center retrospective case series and narrative report describing and reporting the outcomes of the implementation of an on-site CKRT dialysate production system. All adults treated with locally produced CKRT dialysate in December 2021 and January 2022 at UNMH were included. CKRT dialysate was produced locally using intermittent hemodialysis machines, hemodialysis concentrate, sterile parenteral nutrition bags, and connectors made of 3-D printed biocompatible rigid material. Outcomes analyzed included dialysate testing for composition and microbiologic contamination, CKRT prescription components, patient mortality, sequential organ failure assessment (SOFA) scores, and catheter-associated bloodstream infections (CLABSIs).ResultsOver 13 days, 22 patients were treated with 3,645 L of locally produced dialysate with a mean dose of 20.0 mL/kg/h. Fluid sample testing at 48 h revealed appropriate electrolyte composition and endotoxin levels and bacterial colony counts at or below the lower limit of detection. No CLABSIs occurred within 7 days of exposure to locally produced dialysate. In-hospital mortality was 81.8% and 28-day mortality was 68.2%, though illness severity was high, with a mean SOFA score of 14.5.ConclusionsThough producing CKRT fluid with IHD machines is not novel, this report represents the first description of the rapid and successful implementation of a backup plan for local CKRT dialysate production at a large academic medical center in the U.S. during the COVID-19 pandemic. Though conclusions are limited by the retrospective design and limited sample size of our analysis, our experience could serve as a guide for other centers navigating similar severe supply constraints in the future.

Quantitative evaluation of myocardial layer-specific strain using two-dimensional speckle tracking echocardiography in septic patients

BackgroundAlthough global longitudinal strain (GLS) is proven to be reduced and associated with adverse outcomes in septic patients, it has not been elucidated whether or not layer-specific strains are reduced. We aimed to explore the layer-specific strains of left ventricular (LV) for assessing myocardial dysfunction in septic patients.MethodsA prospective observational study of patients with sepsis was conducted in a tertiary hospital in China. Routine two-dimensional speckle tracking echocardiography was performed within 24 h of enrollment. Demographic data, laboratory values, and clinical outcomes were collected.ResultsWe recruited 79 septic patients finally. The mean age of septic patients was 59.4 years old and 45 (57.0%) were male. The median Acute Physiology Age and Chronic Health Evaluation (APACHE II) score, and mean sequential organ failure assessment (SOFA) score of all patients were 19.0 and 7.7, respectively. According to the left ventricular ejection fraction (LVEF) value of 50%, the patients were categorized into two groups: SICM (sepsis-induced cardiomyopathy, LVEF < 50%, n = 22) and non-SICM group ( LVEF ≥ 50%, n = 57). The median LVEF of SICM and non-SICM patients were 41.9% and 58.7%, and SICM patients had less negative layer-specific strain and global strain than that of non-SICM patients. The echocardiographic comparison of non-SICM and healthy controls was conducted to explore the myocardial injuries of non-SICM patients and the non-SICM had worse LS-epi than that of controls (-18.5% vs. -21.4%, p = 0.024).ConclusionThere were 72.2% (57) septic patients presented with non-SICM (LVEF ≥ 50%), and the strain value of epicardium of them was less negative than healthy controls.

The Value of the Sequential Organ Failure Assessment (SOFA) Score and Serum Lactate Level in Sepsis and Its Use in Predicting Mortality.

Background and objective Sepsis is a major health burden that leads to significant morbidity and mortality. Early diagnosis and severity prediction using various scoring systems can reduce themortality rate, particularly in developing nations. There are twoaims of this study. One is to evaluate the prognostic accuracy ofthe Sequential Organ Failure Assessment (SOFA) score and serum lactate levels in patients with sepsis to predict mortality. The other aim is to evaluate the relationship between the SOFA score and lactateso that we may be able to use lactate as a surrogate predictor of organ dysfunction and mortality in sepsis. Methods An observational prognostic accuracy study was conducted in the Department of General Surgery, Intensive Care Unit (ICU), Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India, between 1July 2021 and 1October 2022. We selected 128 patients, calculated their SOFA and lactate levels, and divided them into survivors and non-survivors according to their outcomes after seven days of assessment. The SOFA score and serum lactate levels were assessed as predictors of mortality, and their correlation was studied. Results We observed a significant decreasing trend in the value of the mean SOFA, maximum SOFA, meanlactate, and maximum lactate among survivors, whereas an increasing trend for the same was observed in non-survivors. The receiver operating characteristic (ROC) analysis showed the best diagnostic accuracy of the mean lactate (area under the curve {AUC}=0.996, 95% confidence interval {CI}=0.964-1.00, p≤0.0001). The maximum lactate (AUC=0.987, 95% CI=0.949-0.999, p≤0.0001) and mean SOFA scores (AUC=0.986, 95% CI=0.948-0.999, p≤0.0001) were good at predicting the mortality in sepsis. A slightly lower diagnostic accuracy was found for the maximum SOFA score (AUC=0.969, 95% CI=0.923-0.992, p≤0.0001).There was a strong correlation between the mean lactate and the mean SOFA with a correlation coefficient of 0.883 and p=0.0001. A good correlation was found between maximum lactate and maximum SOFA too (correlation coefficient=0.873, p≤0.0001). Conclusion This study highlights the different predictors of mortality in the patients with sepsis. The maximum lactate was the most accurate in predicting mortality in sepsis. It also demonstrates how serum lactate, due to its strong correlation with the SOFA score, can be used in its place to predict mortality in sepsis and organ dysfunction.

The Experience and the Characteristics of Patients With Tele-ICU Implementation in a Rural Community Hospital.

Background Tele-ICUs are increasingly being used in the US. In Japan, young physicians mainly operate rural community hospitals to manage severely ill patients. However, the introduction of the tele-ICU system in Japan is still uncommon. We introduced a tele-ICU system to a community hospital. The objective of this study is to determine if the newly introduced tele-ICU system is being effectively utilized. Methods This is a single-center, retrospective observational study. We introduced the tele-ICU system to the NachiKatsuura Town Onsen Hospital, Japan, in 2019. Thereafter, we retrospectively explored the characteristics of the consulted cases, the time of consultation, the Sequential Organ Failure Assessment (SOFA) score, and the number of consultations by month from 1st July 2019 to 31st March 2020. The main outcome was the monthly number of consultations, and other measures included the clinical characteristics of the consulted cases. Results A total of 81 cases were referred to the tele-ICU system within nine months. Sixty-two cases, excluding those with missing data, were included in the analysis. The number of consultations was almost constant during the study period and was most frequent during the day. The recommendations from tele-ICU physicians were mostly "advice on the treatment plan." The mean SOFA score was 2.56. Conclusions We introduced a Japanese-type tele-ICU system for Japanese rural community hospitals. Many cases from rural community hospitals that were referred to the tele-ICU systems were moderately severe and did not require urgent transportation. These cases are not indicated for emergency transportation and should be treated in rural community hospitals.

Order Set Usage is Associated With Lower Hospital Mortality in Patients With Sepsis.

To estimate the effect of sepsis order set usage on hospital mortality. Retrospective cohort study. Fifty-four acute care hospitals in the United States from December 1, 2020 to November 30, 2022 involving 104,662 patients hospitalized for sepsis. Hospital mortality. The sepsis order set was used in 58,091 (55.5%) patients with sepsis. Initial mean sequential organ failure assessment score was 0.3 lower in patients for whom the order set was used than in those for whom it was not used (2.9 sd [2.8] vs 3.2 [3.1], p < 0.01). In bivariate analysis, hospital mortality was 6.3% lower in patients for whom the sepsis order set was used (9.7% vs 16.0%, p < 0.01), median time from emergency department triage to antibiotics was 54 minutes less (125 interquartile range [IQR, 68-221] vs 179 [98-379], p < 0.01), and median total time hypotensive was 2.1 hours less (5.5 IQR [2.0-15.0] vs 7.6 [2.5-21.8], p < 0.01) and septic shock was 3.2% less common (22.0% vs 25.4%, p < 0.01). Order set use was associated with 1.1 fewer median days of hospitalization (4.9 [2.8-9.0] vs 6.0 [3.2-12.1], p < 0.01), and 6.6% more patients discharged to home (61.4% vs 54.8%, p < 0.01). In the multivariable model, sepsis order set use was independently associated with lower hospital mortality (odds ratio 0.70; 95% CI, 0.66-0.73). In a cohort of patients hospitalized with sepsis, order set use was independently associated with lower hospital mortality. Order sets can impact large-scale quality improvement efforts.

Serial SOFA-score trends in ICU-admitted COVID-19 patients as predictor of 28-day mortality: A prospective cohort study.

The efficacy of Sequential Organ Failure Assessment (SOFA)score as predictor of clinical outcomes among ICU-admitted COVID-19 patients is still controversial. We aimed to assess whether SOFA-score in different time intervals could predict 28-day mortality compared with other well-acknowledged risk factors of COVID-19 mortality. This observational prospective cohort was conducted on 1057 patients from March 2020 to March 2022 at Masih Daneshvari Hospital, Iran. The univariate and multivariate Cox proportional analysis were performed to assess the hazards of SOFA-score models. Receiver operating characteristic (ROC)curves weredesigned to estimate the predictive values. Mean SOFA-score during first 96 h(HR: 3.82 [CI: 2.75-5.31]), highest SOFA-score (HR: 2.70 [CI: 1.93-3.78]), and initial SOFA-score (HR: 1.65 [CI: 1.30-2.11]) hadstrongest association with 28-daymortality (p < .0001). In contrast, SOFA scoresat 48and 96 has well as Δ-SOFA: 48-0 hand Δ-SOFA: 96-0 hdid not show significant correlations. Amongthem, merely mean SOFA-score (HR: 2.28 [CI: 2.21-3.51]; p < .001) remained as independent prognosticator on multivariate regression analysis; though having less odds of predicting value compared with age (HR: 3.81 [CI: 1.98-5.21]), hypertension (HR: 3.11 [CI: 1.26-3.81]), coronary artery disease [CAD] (HR: 2.82 [CI: 1.51-4.8]), and diabetes mellitus (HR: 2.45 [CI: 1.36-2.99]). The area under ROC (AUROC) for mean SOFA-score (0.77) and highest SOFA-score (0.71) were larger than other SOFA intervals. Calculating the first 96 hof SOFA trends, it was obtained that fatality rate was <12.3% if the score dropped, between 28.8%and 46.29% if the score remained unchanged, and >50.45% if the score increased. To predict the 28-day mortality among ICU-admitted COVID-19 patients, mean SOFA upon first 96 hof ICU stay is reliable; while having inadequate accuracy comparing with well-acknowledged COVID-19 mortality predictors (age, diabetes mellitus, hypertension, CAD). Notably, increased SOFA levels in the course of first 96 hof ICU-admission, prognosticate at least 50%fatality regardless of initial SOFA score.

Efficacy and Safety of Injection Sepsivac® (Heat-killed Mycobacterium W) in Gram-negative Sepsis administered via an Intravenous Route.

As an immunomodulator, the mycobacterium w (Mw) has improved outcomes for patients suffering from severe sepsis. The traditional route of administration for Mw is intradermal (ID), which is limited to administering 0.1 mL per injection (Inj). The intravenous (IV) route can be an alternative to ID. To evaluate the safety and efficacy of Inj Sepsivac® IV in gram-negative sepsis. Present retrospective observational study was conducted in an intensive care unit (ICU) of tertiary care hospital. The study included 30 consecutive patients with presumed gram-negative sepsis within 48 hours of the first organ dysfunction. Patients received Inj Sepsivac® 0.3 mL diluted in 100 mL normal saline to be given as slow IV infusions over at least 15 minutes, every day for 3 consecutive days. Efficacy was assessed by recording the change in vital parameters, sequential organ failure assessment (SOFA) score, and laboratory investigations. Safety was evaluated by the occurrence of allergic reactions including anaphylaxis, the site of infection, and secondary infection. Each patient was followed up for 14 days from the day of enrolment. Mean age of patients with gram-negative sepsis was 62.67 ± 12.77 years with male preponderance (63.3%). Pneumonia (40.1%) and intraabdominal infections (26.7%) were the most common etiologies of sepsis. A significant improvement in all the vitals and mean SOFA scores was observed from day 2 onward. More than half of the patients required ventilator support [17 (56.7%)], and mortality was observed in 7 (25%) patients. None was reported to have a secondary infection. Laboratory parameters improved and oxygen requirement was reduced postday 4 till the end of treatment from baseline. The IV route of administration was found to be efficacious and safe and allow ease of administration in treating gram-negative sepsis. Further large multicentric randomized trials are required to confirm our findings.

Mean SOFA Score in Comparison With APACHE II Score in Predicting Mortality in Surgical Patients With Sepsis.

Sepsis is a medical and surgical emergency that describes the body's systemic immunological response to an infectious process that can lead to end-stage organ dysfunction and death. Various clinical and biochemical parameters serve as indicators of organ dysfunction in patients with sepsis. Most familiar among them are the Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Mortality Prediction Score (MPM), and Simplified Acute Physiology Score (SAPS). A comparative study of APACHE II and SOFA scores was done at the time of admission in a total of 72 patients with sepsis and compared with the mean SOFA score. In our study, the SOFA score was measured serially and the mean SOFA score was calculated. All patients were selected according to the definition of sepsis (Sepsis-3). The ROC curve, the sensitivity, and the specificity were calculated to analyze the diagnostic value of SOFA, APACHE II, and the mean SOFA score. For all statistical tests, a "p-value" less than 0.05 was taken to indicate a significant difference. Our study showed that the mean SOFA score had a sensitivity of 93.65 and a specificity of 100, and on comparing the AUC of mean SOFA with APACHE II (Day1) and SOFA (Day1) - we got the P-value 0.0066 and 0.0008, which shows a statistically significant difference. So, we can say that the mean SOFA score is better than D1(day 1 of admission) APACHE II & SOFA scores in predicting mortality in surgical patients with sepsis. APACHE II and SOFA scores are equally effective in assessing mortality in surgical patients with sepsis at the time of admission. However, if we take serial measurements of SOFA scores and calculate the mean SOFA score it becomes a very useful tool for predicting mortality.

Comparison of hemodynamic indices of dialysis patients in continuous renal replacement therapy and intermittent renal replacement therapy methods with ultrasonic cardiac output monitor in intensive care unit

Introduction: Acute kidney injury (AKI) is a common complication in the intensive care unit (ICU) and is independently associated with end-stage renal disease and higher mortality in the ICU. There are different methods to supporting kidney function in critically ill patients. The renal replacement therapy (RRT) can be conducted continuously, intermittently, or in combination. Objectives: The purpose of our study is to investigate the hemodynamic indices of dialysis patients in the ICU by two methods high flow continuous renal replacement therapy (CRRT) and intermittently renal replacement therapy (IRRT) of ultrasonic cardiac output monitor (USCOM). Patients and Methods: In this study conducted at Sina hospital, patients requiring dialysis hospitalized to the ICU were studied. Around 48 patients benefited from rapid CRRT or IRRT in the opinion of a specialist. Basic patient information was recorded. To check hemodynamic parameters during dialysis, USCOM was carried out to check corrected flow time value (FTc) parameters, systemic vascular resistance (SVR) and cardiac output. Results were compared between the IRRT and CRRT groups. Results: This study was conducted on 48 patients who were candidates for dialysis. Patients were divided into high flow CRRT and IRRT groups based on clinical indications. In CRRT group, 19 patients (79.2%) and in the IRRT group, 20 patients (83.3%) were male (P=0.712). Their mean age was 68.70 ± 8.25 years in the CRRT group and 68.58 ± 7.19 years in the IRRT group. All patients had cardiac output monitored using USCOM or ultrasound. The mean Sequential Organ Failure Assessment (SOFA) score in the CRRT group was 7 and in the IRRT group was 6, with no significant difference among them. FTc value variable or modified flow time in the carotid artery, cardiac output, cardiac index, SVR variable and mean arterial pressure in in the two groups at four evaluated times (before dialysis, 15 minutes later, one hour later and end of dialysis) from the study the difference were not statistically significant. Conclusion: Although previos studies have recommended CRRT, our study showed significant difference may not be existed between IRRT and CRRT.

Analysis of Glycaemic Changes and their Outcome in Critically Ill Non-diabetic Patients Admitted to the ICU: A Cohort Study

Introduction: Critical illness results in physiological and metabolic changes that lead to dysglycaemia, which is associated with morbidity and mortality. There exists a J- or U-shaped relationship between average glucose levels and mortality, emphasising the importance of evaluating glycaemic variability in critical illness. Aim: To assess glycaemic changes in critically ill patients and their association with Intensive Care Unit (ICU) outcomes. Materials and Methods: The prospective cohort study was conducted from August 2018 to August 2019. A total of 100 non-diabetic critically ill patients admitted to the ICU were observed for seven days. The severity of illness was evaluated using the Glasgow Coma Score (GCS) and Sequential Organ Failure Assessment (SOFA) scores. Plasma glucose levels were recorded every four hours in the ICU. Patients were followed for a maximum of seven days or until discharge or death. They were categorised into hypoglycaemia, normoglycaemia, or stress hyperglycaemia groups for analysis. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 24.0. Results: The study included 64 male and 36 female patients, with an average mean age of 55.90±16.51 years (range: 18- 86 years). Among the 100 patients, 21 died within the sevenday hospitalisation period. Among these, two were in the hypoglycaemic group, 13 were in the normoglycaemic group, and six were in the stress hyperglycaemic group. The patients had a mean SOFA score of 11.55±2.20, which was significantly higher compared to patients without organ failure (mean score: 2.54±2.55), with a statistically significant association (p&lt;0.01). Similarly, patients who died during hospitalisation had a very high SOFA score (mean score: 9.76±3.36), also statistically significant (p&lt;0.01). Conclusion: Critically ill patients in the stress hyperglycaemia and hypoglycaemia groups during their ICU stay had a worse prognosis compared to patients with normoglycaemia. Hypoglycaemia during the ICU stay was associated with the poorest outcome. Maintaining normoglycaemia can significantly reduce morbidity and mortality in critically ill non-diabetic patients; therefore, considering Continuous Glucose Monitoring Systems (CGMS) for more frequent glycaemic monitoring and reducing glycaemic variability may lead to better outcomes in the ICU.

Outcome prediction using sequential organ failure assessment (SOFA) score and serum lactate levels in organophosphate poisoning.

Organophosphorus compounds are widely used as pesticides in agriculture practicing countries like India. Since it is readily available and accessible, it is one of the most commonly used agents for suicidal poisoning. The current study was undertaken to evaluate the performance of the SOFA score (scoring system) and the serum lactate level (laboratory parameter) as a mortality predictor in organophosphorus poisoning. This prospective observational study was conducted at AIIMS, Bhubaneswar, for 17 months. The study population included all patients with an alleged history of ingestion of organophosphorus (OP) compounds reporting to the casualty. The receiver operating characteristic (ROC) curve and the logistic regression analysis were used for the analysis. In our study, 75 patients with OP poisoning were studied after satisfying the inclusion criteria. OP poisoning was commonly seen in married males aged 21-40 years. Twelve (16%) patients died during the process of treatment. There was a statistically significant difference in the mean SOFA score, serum lactate level, pH value, and mean duration of hospital stay between the discharged and the deceased patients. In the current study, the ROC curve analysis used to assess the predictor of the outcome of OP poisoning showed that the area under the curve for SOFA score and serum lactate level were 0.794 (95% CI 0.641-0.948) and 0.659 (95% CI 0.472-0.847), respectively. Sequential Organ Failure Assessment (SOFA) score is significantly associated with the outcome of organophosphate poisoning and can be utilized to predict mortality.

Systemic inflammatory response syndrome criteria (SIRS) and sepsis 3 criteria for assessing outcomes in sepsis: A prospective observational study.

Sepsis is a major cause of death in hospitalised patients worldwide. Most studies for assessing outcomes in sepsis are from the western literature. Sparse data from Indian settings are available comparing the systemic inflammatory response syndrome (SIRS), Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) (sepsis 3 criteria) for assessing outcomes in sepsis. In this study, we aimed to compare the SIRS criteria and sepsis 3 criteria to assess disease outcome at day 28 (recovery/mortality) in a North Indian tertiary care teaching hospital. A prospective observational study was performed in the Department of Medicine from 2019 to early 2020. Patients admitted to the medical emergency with clinical suspicion of sepsis were included. Systemic inflammatory response syndrome, qSOFA and SOFA scores were calculated at the time of presentation to the hospital. Patients were followed through the course of their hospital stay. Out of 149 patients, 139 were included in the analysis. Patients who died had significantly higher mean SOFA, qSOFA scores and mean change in SOFA score than patients who survived (P value <0.01). There was no statistical difference between recovery and deaths at similar SIRS scores. A 40.30% fatality rate was recorded. Systemic inflammatory response syndrome had low Area Under Curve (AUC) (0.47) with low sensitivity (76.8) and specificity (21.7). SOFA had the maximum AUC (0.68) compared to qSOFA (0.63) and SIRS (0.47). SOFA also had the maximum sensitivity (98.1) while the qSOFA score had the maximum specificity (84.3). SOFA and qSOFA scores had superior predictive ability as compared to the SIRS score in assessing mortality in sepsis patients.