Median Intensive Care Unit Length Research Articles

Neonates With Right Aortic Arch Requiring Arch Reconstruction: A Single-Institution Experience

BackgroundReconstruction of a right aortic arch is rarely required in the newborn period and has rarely been reported. MethodsAll patients who underwent a right aortic arch repair in the neonatal period from a single institution were retrospectively reviewed. The primary outcome measures included survival, complications, and reintervention. ResultsBetween 1984 and 2020, 15 patients were identified. Nine patients (60%) presented with an interrupted aortic arch, 5 with a hypoplastic arch (33%), and 1 with anomalous origin of the brachiocephalic vessels (7%). All patients had associated complex congenital heart disease. Median age at surgery was 6 days (range, 2-29 days); median weight was 3.11 kg (range, 2.5-4.18 kg). Genetic syndromes were prevalent and 77% of interrupted aortic arch patients had DiGeorge syndrome. Surgical techniques included end-to-side (27%), end-to-end (27%), or side-to-side anastomosis (13%) and placement of an interposition graft (7%); 65% required patch augmentation. Median intensive care unit and total hospital length of stay were 20 days (range, 7-92 days) and 28 days (range, 10-240 days), respectively. At a median follow-up of 3.97 years (range, 0.19-36 years), 13 of 15 patients were alive (87%). We found vocal cord paralysis in 27%, hemidiaphragm paralysis in 13%, and considerable airway compression in 27%. Overall, 27% patients required reintervention on the aortic arch: 2 surgical and 2 percutaneous balloon dilation. ConclusionsRight aortic arch reconstruction in the newborn period is rare and associated with complex lesions with an acceptable reintervention rate.

Outcomes of non-COVID-19 critically ill patients during the COVID-19 pandemic : Aretrospective propensity score-matched analysis.

BackgroundCoronavirus disease 2019 (COVID-19) disrupts routine care and alters treatment pathways in every medical specialty, including intensive care medicine, which has been at the core of the pandemic response. The impact of the pandemic is inevitably not limited to patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their outcomes; however, the impact of COVID-19 on intensive care has not yet been analyzed.MethodsThe objective of this propensity score-matched study was to compare the clinical outcomes of non-COVID-19 critically ill patients with the outcomes of prepandemic patients. Critically ill, non-COVID-19 patients admitted to the intensive care unit (ICU) during the first wave of the pandemic were matched with patients admitted in the previous year. Mortality, length of stay, and rate of readmission were compared between the two groups after matching.ResultsA total of 211 critically ill SARS-CoV‑2 negative patients admitted between 13 March 2020 and 16 May 2020 were matched to 211 controls, selected from a matching pool of 1421 eligible patients admitted to the ICU in 2019. After matching, the outcomes were not significantly different between the two groups: ICU mortality was 5.2% in 2019 and 8.5% in 2020, p = 0.248, while intrahospital mortality was 10.9% in 2019 and 14.2% in 2020, p = 0.378. The median ICU length of stay was similar in 2019: 4 days (IQR 2–6) compared to 2020: 4 days (IQR 2–7), p = 0.196. The rate of ICU readmission was 15.6% in 2019 and 10.9% in 2020, p = 0.344.ConclusionIn this retrospective single center study, mortality, ICU length of stay, and rate of ICU readmission did not differ significantly between patients admitted to the ICU during the implementation of hospital-wide COVID-19 contingency planning and patients admitted to the ICU before the pandemic.

Early Outcomes of Surgical Stabilisation of Traumatic Rib Fractures: Single-Center Review With a Real-World Evidence Perspective

BackgroundRandomized controlled trials have demonstrated that surgical stabilization of rib fractures (SSRF) in selected trauma patients is associated with potential benefits. This study evaluates the real-world outcomes of SSRF since its implementation at Westmead Hospital, Australia. We hypothesize these outcomes to be similar to that reported by best-evidence in the literature. Materials and methodsA retrospective analysis of data on all consecutive SSRF performed between January 2013 to December 2018 was completed. ResultsSixty-three patients (54 male; average age 55.9 ± 14.1 y) with median ISS 24 (IQR 17;30) underwent SSRF. Thirty-seven patients were admitted to Intensive Care Unit (ICU), with median ICU length of stay (LOS) 10.0 (5.0-17.0) d. Median hospital LOS was 15.5 (10.0-24.8) d. Fifty-five (87.3%) patients did not have any surgery-specific complications. The highest observed surgical morbidity was wound infection (n = 4, 4.7%). There was one mortality after rib fixation that was not related to surgery. SSRF within 3 d of hospital presentation in ventilated patients with flail chest was associated with significantly reduced median ICU LOS (3.0 [2.0;4.0] versus 10.0 [9.3;13.0] d; P = 0.03). Early (2013-2015) versus late (2015-2018) phase SSRF implementation demonstrated no significant difference in outcome variables. ConclusionExperience with SSRF demonstrates early outcomes similar to best-evidence in the existing literature. As a quality assurance tool, ongoing evaluation of real-world data is needed to ensure that outcomes remain consistent with benchmarks available from best-evidence.

Contemporary early results of late repair of tetralogy of Fallot in children: a single-centre case series.

To describe the early results of complete repair of tetralogy of Fallot (TOF) in children older than one year of age. We identified all patients older than one year of age who underwent TOF repair between 2007 and 2017. Data collected included type of surgical repair, survival at 30 days after surgery, reintervention within 30 days of surgery, length of stay in the intensive care unit (ICU), length of stay in hospital, and degree of residual right ventricular outflow tract (RVOT) stenosis and pulmonary insufficiency 30 days after surgery. 125 children (median age 4.4 years, interquartile range [IQR] 3–5.7) underwent complete repair of TOF, with pulmonary valve preservation in 66%, a transannular patch in 19%, and a valved right ventricular-to-pulmonary artery conduit in 15%. All patients survived. There were twelve (9.6%) reinterventions. Median ICU length of stay was 7 days and median hospital length of stay was 12 days. Significant residual RVOT stenosis was present in 7.2% and significant pulmonary insufficiency in 19.2%. Patients with a transannular patch had a significantly higher proportion of significant residual RVOT stenosis and significant pulmonary insufficiency compared with the other types of surgical repair. Compared with the existing literature on complete late repair of TOF in children, this study showed good early results with no mortality, similar rates of reintervention and valve-preserving surgery, higher ICU and hospital length of stay, higher incidence of significant residual RVOT stenosis, and lower incidence of significant pulmonary insufficiency. Repair with a transannular patch was a risk factor for significant residual RVOT stenosis and significant pulmonary insufficiency.

Acute poisonings presenting to King Edward VIII hospital intensive care unit in Durban, South Africa.

Background Acute poisoning is a potentially preventable burden on the healthcare systems and a significant cause of morbidity and mortality worldwide. Improved knowledge of the patterns of poisoning, the clinical course and outcomes of these cases may help create better preventive and management approaches. Objectives To describe the demographics, clinical characteristics and outcomes of patients with acute poisonings who were admitted to a multidisciplinary intensive care unit (ICU) at King Edward VIII Hospital, Durban, South Africa. Methods A retrospective observational chart review of patients admitted to the study ICU with acute poisoning over a 24-month period (1 July 2015 - 30 June 2017). Results A total of 85 patients with acute poisoning were admitted to the ICU during the study period. There was a female preponderance (55%) with a median age of 28 years. ICU mortality was 16.5% with a median ICU length of stay of 3 days. Tricyclic antidepressants (TCA) were the most common toxin identified (16.5%). The ingestion of amphetamines was associated with a statistically significant increase in mortality (100.0% v. 13.4%; p=0.04). Ethylene glycol was a commonly ingested toxin (9.4% of admissions) and had a high mortality rate of 37.5% that was not statistically significant (p=0.121). Referral for inotropic support, a Glasgow Coma Scale ≤5 and metabolic acidosis on admission were associated with higher ICU mortality. Conclusion Acute poisoning results in potentially preventable ICU admission and mortality. TCA poisoning was the most common presentation and this warrants review of TCA prescription practice. Ingestion of illicit drugs, ethylene glycol or presentation with a markedly reduced level of consciousness, shock or metabolic acidosis should alert treating physicians to a possible elevated risk of adverse outcomes. Contributions of the studyThis is the first study to describe acute poisoning patterns in KwaZulu-Natal from a critical care perspective. This will increase knowledge of common toxins and the presentations that lead to critical care referral. Furthermore, prescription practices for common toxins like TCAs need to be reviewed as a prevention strategy.

Super Glenn for staged biventricular repair: impact on left ventricular growth?

The Super Glenn procedure involves targeted increased in blood flow to left sided heart structures with fenestrated atrial septation. The objective of this study was to examine the outcomes of patients who had this procedure as a part of biventricular staging and specifically evaluate the effect on dimensions of left heart structures. Data for patients who had this procedure between 2005 and 2019 were retrospectively identified. Thirty-seven patients were identified. Most common diagnosis was hypoplastic left heart syndrome in 40% (n = 15). On echocardiography, the median mitral valve z score was -2.26. On cardiac magnetic resonance imaging, median indexed left ventricular end-diastolic volume was 31.5 ml/m2 and mitral/tricuspid inflow ratio was 0.35. The median age at Super Glenn was 2.3 years (interquartile range 1.5-3.6) while median weight was 12 kg (interquartile range 9.8-14). There were no early/hospital deaths. The median intensive care unit length of stay was 4 days, and median hospital length of stay was 10 days. Median follow-up for the entire cohort was 3 years (range 15 days to 13.2 years). There was a statistically significant increase in indexed left ventricular dimensions. There were 5 deaths (14%). Three patients (8%) underwent heart transplant. Freedom from death/transplant was 79% at 5 years. Seven patients (19%) needed a reoperation. Twenty-three patients (62%) underwent biventricular conversion after a median of 11.3 months after Super Glenn. The Super Glenn procedure achieves consistent increase in left ventricular dimensions. This may be a useful strategy to help achieve a successful biventricular circulation in patients with borderline left ventricle. The superiority/non-inferiority of this approach over the conventional Fontan pathway is unclear.

High Incidence of Barotrauma in Patients With Severe Coronavirus Disease 2019.

Objective.:To report the high incidence of barotrauma in critically ill patients admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19) and to discuss its implications.Design.:Retrospective cohort study.Setting.:ICU of an academic county hospital in Los Angeles, CA admitted from March 15-June 20, 2020.Patients.:77 patients with COVID-19 pneumonia. 75 patients met inclusion criteria.Results.:21% of patients with severe COVID-19 sustained barotrauma (33% of patients receiving IMV, 8% of patients receiving (NIV). There were no differences between the barotrauma and non-barotrauma groups regarding demographics, illness severity, or medications received, nor tidal volume or average/peak airway pressures in those receiving IMV. In the barotrauma group there was a greater proportion of patients receiving therapeutic anticoagulation (81% vs. 47%, p = 0.023) and ventilated using airway pressure release ventilation mode (13% vs. 0%, p = 0.043). Barotrauma was associated with increased likelihood of receiving a tracheostomy (OR 2.58 [0.23-4.9], p = 0.018]), longer median ICU length of stay (17 days vs. 7 days, p = 0.03), and longer median length of hospitalization (26 days vs. 14 days, p < 0.001). There was also a trend toward prolonged median duration of IMV (12.5 days vs 7 days, p = 0.13) and higher average mortality (56% vs 37%, p = 0.25).Conclusions.:Barotrauma is seen in 5-12% of patients with ARDS receiving IMV and is exceedingly rare in patients receiving NIV. We report a high incidence of barotrauma observed in critically ill patients with COVID-19 requiring either NIV or IMV. While there was a trend toward increased mortality in patients with barotrauma, this did not reach statistical significance. The increased incidence of barotrauma with COVID-19 may be a product of the pathophysiology of this disease state and a heightened inflammatory response causing rampant acute lung injury. Evidence-based medicine and lung-protective ventilation should remain the mainstay of treatment.

Clinical characteristics and outcomes of critically ill COVID-19 patients in Tokyo: a single-center observational study from the first wave

BackgroundMany studies have been published about critically ill coronavirus disease 2019 (COVID-19) during the early phases of the pandemic but the characteristic or survival of critically ill Japanese patients have not yet been investigated. We sought to investigate the characteristics, inflammatory laboratory finding trends, and outcomes among critically ill Japanese patients who were admitted to the intensive care unit (ICU) with the first wave of COVID-19.MethodsA retrospective observational study was performed in a single institution in the center of Tokyo. Laboratory-confirmed COVID-19 patients admitted to the ICU from March 19 to April 30, 2020 were included. Trends for significant inflammatory laboratory findings were analyzed. In-hospital death, days of mechanical ventilation or oxygen supplementation, days of ICU or hospital stay were followed until May 26, 2020.ResultsTwenty-four patients were included. Median age was 57.5 years, and 79% were male. The neutrophil-to-lymphocyte ratio was elevated to a median of 10.1 on admission and peaked on Day 10 of illness. Seventeen patients were intubated on Day 11 of illness and received mechanical ventilation. One patient underwent extracorporeal membrane oxygenation. The majority (88%) received systemic steroids, including 16 patients who received high dose methylprednisolone (500–1000 mg). Favipiravir was used in 38% of patients. Two patients, including 1 who refused intensive care, died. Eighteen patients were discharged. Median length of ICU and hospital stay for all patients was 6 and 22 days, respectively. Median length of ventilator dependency was 7 days. Four patients underwent a tracheostomy and received prolonged ventilation for more than 21 days. One patient receiving mechanical ventilation died. All survivors discontinued ventilator use.ConclusionsMortality was remarkably low in our single institutional study. Three survivors received mechanical ventilation for more than 3 weeks. Trends of clinically significant laboratory markers reflected the clinical course of COVID-19.

Severity of shock, rate of physiological stabilization and organ failure in healthy women admitted to the intensive care unit following major peripartum hemorrhage: A retrospective, descriptive study.

To describe shock severity, physiological stabilization and organ failure in healthy women admitted to the intensive care unit (ICU) after major peripartum hemorrhage (PPH). Retrospective, descriptive, single center study. Twenty-nine women median age 33years (interquartile range [IQR] 30-36) and gravidity 5 pregnancies (IQR 3-9) were studied. One woman died. The median maternal admission hematocrit was 28.8 (IQR 25.7-32.4). Median transfusion rates were nine units of packed red blood cells (IQR 7-12.25), eight fresh frozen plasma (IQR 6-12), 17 platelets (IQR 10-22) and 15 cryoprecipitate (IQR 9.75-20). Blood pressure dropped significantly in the six hours following ICU admission. Nonetheless, lactate decreased from 3.23mmol/L to 1.54mmol/L within 24h of ICU admission, renal and pulmonary function were unaffected and coagulopathy was never observed. Two-thirds of the women underwent hysterectomy. One-third underwent repeated surgery. The median length of ICU stay was <48h and that of mechanical ventilation was <24h. Increased transfusion rates correlated with lengthier ICU admission (p≤0.01 regardless of blood product). Ongoing hemorrhage in women with severe PPH manifests subtly and often requires active intervention. Hemorrhage control is required to achieve physiological stabilization and minimize organ damage.

Multisystem outcomes and predictors of mortality in critically ill patients with COVID-19: Demographics and disease acuity matter more than comorbidities or treatment modalities.

We sought to describe characteristics, multisystem outcomes, and predictors of mortality of the critically ill COVID-19 patients in the largest hospital in Massachusetts. This is a prospective cohort study. All patients admitted to the intensive care unit (ICU) with reverse-transcriptase-polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 14, 2020, and April 28, 2020, were included; hospital and multisystem outcomes were evaluated. Data were collected from electronic records. Acute respiratory distress syndrome (ARDS) was defined as PaO2/FiO2 ratio of ≤300 during admission and bilateral radiographic pulmonary opacities. Multivariable logistic regression analyses adjusting for available confounders were performed to identify predictors of mortality. A total of 235 patients were included. The median (interquartile range [IQR]) Sequential Organ Failure Assessment score was 5 (3-8), and the median (IQR) PaO2/FiO2 was 208 (146-300) with 86.4% of patients meeting criteria for ARDS. The median (IQR) follow-up was 92 (86-99) days, and the median ICU length of stay was 16 (8-25) days; 62.1% of patients were proned, 49.8% required neuromuscular blockade, and 3.4% required extracorporeal membrane oxygenation. The most common complications were shock (88.9%), acute kidney injury (AKI) (69.8%), secondary bacterial pneumonia (70.6%), and pressure ulcers (51.1%). As of July 8, 2020, 175 patients (74.5%) were discharged alive (61.7% to skilled nursing or rehabilitation facility), 58 (24.7%) died in the hospital, and only 2 patients were still hospitalized, but out of the ICU. Age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04-1.12), higher median Sequential Organ Failure Assessment score at ICU admission (OR, 1.24; 95% CI, 1.06-1.43), elevated creatine kinase of ≥1,000 U/L at hospital admission (OR, 6.64; 95% CI, 1.51-29.17), and severe ARDS (OR, 5.24; 95% CI, 1.18-23.29) independently predicted hospital mortality.Comorbidities, steroids, and hydroxychloroquine treatment did not predict mortality. We present here the outcomes of critically ill patients with COVID-19. Age, acuity of disease, and severe ARDS predicted mortality rather than comorbidities. Prognostic, level III.

Esophagectomy combined with off-pump coronary artery bypass grafting through left posterolateral incision is safe and feasible for esophageal cancer associated with coronary artery disease.

Controversy still exists as to whether surgical treatment has any impact on the long-term survival of esophageal cancer (EC) patients with coronary artery disease treated with curative esophagectomy combined with off-pump coronary artery bypass grafting (OPCABG). Therefore, the aim of this study was to introduce and assess the effect of esophagectomy combined with OPCABG on both short- and long-term outcomes. From January 2010 to January 2015, 1428 EC or esophagogastric junction cancer patients underwent surgical treatment at Henan Chest Hospital, Zhengzhou, China. The clinical data of 25 patients who underwent EC resection through a left thoracotomy following OPCABG and the perioperative characteristics and follow-up results were analyzed. The majority of the patients were male, and the EC stage was predominantly cT2N0-1M0 II. The most common pathological types were squamous cell carcinoma. The EC surgeries consisted of 15 chest anastomosis procedures and 10 cervical anastomosis procedures with aortocoronary graft implantation (mean: 2.36 grafts per patient). The mean total operative time was 330.8 ± 83.5minutes. The median intensive care unit and hospital lengths of stay were 1.72 and 21.16days, respectively. Resection without macroscopic residual disease (R0) was achieved in all of the patients. The most frequent complications included pulmonary infections (24%), arrhythmias (24%), pleural effusion (12%), and esophageal anastomotic leakage (8%). There were no postoperative deaths or myocardial infarctions within 30 days after the surgery. The overall 1-, 3-, and 5-year survival rates were 88%, 40%, and 24%, respectively, with a median survival time of 43months. In the short-term, radical resection of EC following OPCABG is a safe and feasible treatment with low postoperative mortality rates. In the long-term, simultaneous surgery is acceptable and is associated with favorable overall and disease-free survival.

A Retrospective Comparison of the Effectiveness and Safety of Intravenous Olanzapine Versus Intravenous Haloperidol for Agitation in Adult Intensive Care Unit Patients.

Intravenous (IV) olanzapine could be an alternative to first-generation antipsychotics for the management of agitation in intensive care unit (ICU) patients. We compared the effectiveness and safety of IV olanzapine to IV haloperidol for agitation management in adult patients in the ICU at a tertiary academic medical center. A retrospective cohort study was conducted. The primary outcome was the proportion of patients who achieved a Richmond Agitation Sedation Scale (RASS) score of < +1 within 4 hours of IV olanzapine or IV haloperidol administration. Secondary outcomes included the proportion of patients who required rescue medications for agitation within 4 hours of initial IV olanzapine or IV haloperidol administration, incidence of adverse events and ICU length of stay. In the 192 patient analytic cohort, there was no difference in the proportion of patients who achieved a RASS score of < +1 within 4 hours of receiving IV olanzapine or IV haloperidol (49% vs. 42%, p = 0.31). Patients in the IV haloperidol group were more likely to receive rescue medications (28% vs 55%, p < 0.01). There was no difference in the incidence of respiratory events or hypotension between IV olanzapine and IV haloperidol. Patients in the IV olanzapine group experienced more bradycardia (11% vs. 3%, p = 0.04) and somnolence (9% vs. 1%, p = 0.02) compared to the IV haloperidol group. Patients in the IV olanzapine group had a longer median ICU length of stay (7.5 days vs. 5 days, p = 0.04). In this retrospective cohort study, there was no difference in the effectiveness of IV olanzapine compared to IV haloperidol for the management of agitation. IV olanzapine was associated with an increased incidence of bradycardia and somnolence.

Characteristics and outcomes of patients admitted to adult intensive care units in Hong Kong: a population retrospective cohort study from 2008 to 2018

BackgroundGlobally, mortality rates of patients admitted to the intensive care unit (ICU) have decreased over the last two decades. However, evaluations of the temporal trends in the characteristics and outcomes of ICU patients in Asia are limited. The objective of this study was to describe the characteristics and risk adjusted outcomes of all patients admitted to publicly funded ICUs in Hong Kong over a 11-year period. The secondary objective was to validate the predictive performance of Acute Physiology And Chronic Health Evaluation (APACHE) IV for ICU patients in Hong Kong.MethodsThis was an 11-year population-based retrospective study of all patients admitted to adult general (mixed medical-surgical) intensive care units in Hong Kong public hospitals. ICU patients were identified from a population electronic health record database. Prospectively collected APACHE IV data and clinical outcomes were analysed.ResultsFrom 1 April 2008 to 31 March 2019, there were a total of 133,858 adult ICU admissions in Hong Kong public hospitals. During this time, annual ICU admissions increased from 11,267 to 14,068, whilst hospital mortality decreased from 19.7 to 14.3%. The APACHE IV standard mortality ratio (SMR) decreased from 0.81 to 0.65 during the same period. Linear regression demonstrated that APACHE IV SMR changed by − 0.15 (95% CI − 0.18 to − 0.11) per year (Pearson’s R = − 0.951, p < 0.001). Observed median ICU length of stay was shorter than that predicted by APACHE IV (1.98 vs. 4.77, p < 0.001). C-statistic for APACHE IV to predict hospital mortality was 0.889 (95% CI 0.887 to 0.891) whilst calibration was limited (Hosmer–Lemeshow test p < 0.001).ConclusionsDespite relatively modest per capita health expenditure, and a small number of ICU beds per population, Hong Kong consistently provides a high-quality and efficient ICU service. Number of adult ICU admissions has increased, whilst adjusted mortality has decreased over the last decade. Although APACHE IV had good discrimination for hospital mortality, it overestimated hospital mortality of critically ill patients in Hong Kong.

TRANSCATHETER VERSUS SURGICAL AORTIC VALVE REPLACEMENT: FIRST EXPERIENCE WITH A NEW TAVI SYSTEM

The aim: to reveal early results after transapical TAVI with a new self-manufactured XPand system, comparing them with SAVR and common transfemoral TAVI outcomes. Materials and methods: Eighty-four patients (mean age 79,5±10,2 years) with severe aortic stenosis were operated on from January 2016 to February 2019. Nine patients had undergone the TAVI (two with transfemoral access route and seven with transapical, using the XPand system). SAVR was performed in seventy five patients. For the latter, we estimate the in-hospital mortality, complication rates, intensive care unit and total hospital length of stay. Results: There was no intraoperative mortality. In the TAVI group, the frequency of intraoperative and postoperative complications was significantly lower (p<0.01). The SAVR group showed higher median intensive care unit length of stay (104 h, IQR 72 -112 versus 29 h, IQR 20-35,p<0.01), hemodynamic support duration (100,98 ± 78 minutes versus 11.13 ± 7.89 minutes, p<0.01) and paravalvular leakage causality (9,33% versus 0%). No significant difference in results depending on the TAVI access routes was obtained. Conclusions: We conclude that TAVI provides an alternative to the conventional approach in patients with severe aortic stenosis aged over 75 years. No significant difference in mortality rate between TAVI and SAVR groups was found. A novel transapical TAVI device is associated with good short-term results and lower complication rate.

Development of septic shock and prognostic assessment in critically ill patients with coronavirus disease outside Wuhan, China.

The study aims to illustrate the clinical characteristics and development of septic shock in intensive care unit (ICU) patients confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and to perform a comprehensive analysis of the association between septic shock and clinical outcomes in critically ill patients with coronavirus disease (COVID-19). Patients confirmed with SARS-CoV-2 infection, who were admitted to the ICU of the Third People's Hospital of Shenzhen from January 1 to February 7, 2020, were enrolled. Clinical characteristics and outcomes were compared between patients with and without septic shock. In this study, 35 critically ill patients with COVID-19 were included. Among them, the median age was 64 years (interquartile range [IQR] 59-67 years), and 10 (28.4%) patients were female. The median ICU length of stay was 16 days (IQR 8-23 days). Three (8.6%) patients died during hospitalization. Nine (25.7%) patients developed septic shock in the ICU, and these patients had a significantly higher incidence of organ dysfunction and a worse prognosis than patients without septic shock. Septic shock is associated with a poor outcome in critically ill COVID-19 patients and is one of the hallmarks of the severity of patients receiving ICU care. A dysregulated immune response, uncontrolled inflammation, and coagulation disorders are strongly associated with the development and progression of COVID-19-related septic shock.

Mortality Rates in Mechanically Ventilated Patients with COVID-19

Background/Objective: &#x0D; High mortality rates among mechanically ventilated COVID-19 intensive care unit (ICU) patients have raised concerns regarding use of mechanical ventilation in management of patients with COVID-19. Additional data is needed in this discussion to better understand treatment strategies for this vulnerable population. We conducted a study to examine length of stay, duration of mechanical ventilation, mortality, and risk factors for death in critically ill patients with COVID-19. &#x0D; &#x0D; Methods: &#x0D; Observational study in patients admitted to Eskenazi Health and Indiana University Health Methodist ICUs. Participants were 18 years and older patients admitted to the ICU from March 1 2020 to April 27, 2020 who tested positive for COVID-19. Primary outcomes for this study were in-hospital mortality, duration of mechanical ventilation, and the length of stay in the ICU. &#x0D; &#x0D; Results: &#x0D; The study cohort was made up of 242 patients. The mortality rate was 19.8% (48/242) for the overall cohort and 20.5% (38/185) for mechanically ventilated patients. Age was a significant risk factor for in-hospital mortality [increased hazard in in-hospital mortality: age 65-74 years (HR: 3.1, 95%Cl=1.2-7.9, p=0.021), age 75+ (HR: 4.1, 95%CI=1.6-10.5, p=0.003) compared to those younger than 65]. In our Cox’s proportional hazard model, ESRD (HR:5.9, 95%CI=1.3-26.9, p=0.021) along with age were the only risk factors with statistical significance. The median duration of mechanical ventilation in the overall cohort was 9.3 days (IQR=-5.7-13.7). In patients that died, median ICU length of stay was 8.7 days (IQR=4.0-14.9), compared to 9.2 days (IQR=4.0-14.0) in those discharged alive. &#x0D; &#x0D; Conclusion/Clinical Impact: &#x0D; We found lower mortality rates and longer length of stays in our cohort than in previous studies. While more data is needed, this study supports continued use of mechanical ventilation ARDS recommendations for treating patients with ARDS from COVID-19. Further, this data potentially shows a benefit to not having a strained healthcare system.

Nature and impact of in-hospital complications associated with persistent critical illness

Background: Persistent critical illness (PerCI) is defined as an intensive care unit (ICU) admission lasting ≥ 10 days. The in-hospital complications associated with its development are poorly understood. Aims: To test whether PerCI is associated with a greater prevalence, rate and specific types of in-hospital complications. Methods: Single-centre, retrospective, observational case-control study. Results: We studied 1200 patients admitted to a tertiary ICU from 2010 to 2015. Median ICU length of stay was 16 days (interquartile range [IQR], 12-23) for PerCI patients v 2.3 days (IQR, 1.1-3.7) for controls, and median hospital length of stay was 41 days (IQR, 22-75) v 8 days (IQR, 4-17) respectively. A greater proportion of PerCI patients received acute renal replacement therapy (37% v 6.8%) or underwent reintubation (17% v 1%) and/or tracheostomy (36% v 0.6%); P < 0.0001. Despite these complications, PerCI patients had similar hospital mortality (29% v 27%; P = 0.53). PerCI patients experienced a greater absolute number of complications (12.1 v 4.0 complications per patient; P < 0.0001) but had fewer exposure-adjusted complications (202 v 272 complications per 1000 hospital bed-days; P < 0.001) and a particularly high overall prevalence of specific complications. Conclusions: PerCI patients experience a higher prevalence, but not a higher rate, of exposure-adjusted complications. Some of these complications appear amenable to prevention, helping to define intervention targets in patients at risk of PerCI. Funding: Austin Hospital Intensive Care Trust Fund.

Use of hospital resources in the care of patients with intermediate risk pulmonary embolism.

Risk stratification and management of hemodynamically stable pulmonary embolism remains challenging. Professional societies have published stratification schemes, but little is known about the management of patients with intermediate risk pulmonary embolism. We describe the care of these patients at an academic health system. Patient encounters from 1 January 2016 to 30 June 2017 were retrospectively identified utilizing a multihospital, electronic health record-based data warehouse. Using the 2019 European Society of Cardiology criteria, differences in hospital resource utilization, defined as intensive care unit admission, use of invasive therapies, and length of stay, were examined in patients with intermediate risk characteristics. A cohort of 322 intermediate risk patients, including 165 intermediate-low and 157 intermediate-high risk patients, was identified. Intermediate-high risk patients more often underwent catheter-directed therapy (14.0% vs. 1.8%; P<0.001) compared to intermediate-low risk patients and had a 50% higher rate of intensive care unit admission (relative risk 1.50; 95% confidence interval 1.06, 2.12; P=0.023). There was no difference in median intensive care unit length of stay (2.7 vs. 2.0 days; P=0.761) or hospital length of stay (5.0 vs. 5.0 days; P=0.775) between intermediate-high risk and intermediate-low risk patients. Patients that underwent invasive therapies had a 3.8-day shorter hospital length of stay (beta -3.75; 95% confidence interval -6.17, -1.32; P=0.002). This study presents insights into the hospital resource utilization of patients with intermediate risk pulmonary embolism. The 2019 European Society of Cardiology risk stratification criteria are a clinically relevant scheme that identifies patients more often treated with intensive care unit admission and advanced therapies.

Extracorporeal life support rewarming rate is associated with survival with good neurological outcome in accidental hypothermia.

Favourable outcomes have been demonstrated after extracorporeal life support (ECLS) facilitated rewarming for severe accidental hypothermia. The clinical impact of varying rewarming rates however is unclear. We sought to quantify the change in the probability of good neurological outcome with ECLS rewarming rate and identify the optimal rewarming rate threshold. We performed a secondary analysis of the International ACcidental Hypothermia Extracorporeal Life Support Collaborators, an individual patient data data set (n = 658) for ECLS-assisted rewarming for accidental hypothermia. The independent variable of interest was rewarming rate. The primary outcome was survival with good neurological status. We applied an adjusted marginal effects model to quantify the probability of good neurological outcome over clinically observed rewarming rates. We examined strata defined by sex, initial potassium level and history of asphyxiation. Of 658 cases, the median age and initial core temperature were 36 years (22-55) and 24.5°C (22.1-26.2) respectively; 190 (29%) were female, and 547 (83%) had a non-perfusing initial cardiac rhythm. The mean rewarming rate was 7.0°C/h. The median ECLS duration was 5.8 h (range: 0.5-158 h). The overall survival was 46% (n = 303/658), and good neurological outcome was 40% (n = 265/658). The median intensive care unit and hospital length of stay was 5 days (range: 1-35 days) and 18 days (range: 1-106 days), respectively. Marginal effects analysis demonstrated a 1.9% decrease in the probability of survival with good neurological outcome for each 1°C/h increase in rewarming. Across the reported range of rewarming rates (0.05-30.8°C/h), the probability of good neurological outcome declined from 49.6% to 4.1% for an average patient. The relationship was similar within various subgroups. The optimal cut-off threshold for the rate of rewarming to distinguish between a good and poor neurological outcome was ≤5.0°C/h. Among cases with severe accidental hypothermia treated with ECLS, slower rewarming rates are associated with improved survival with good neurological outcomes. Slow rewarming, at rates ≤5.0°C/h, may improve clinical outcomes.

Caravan explosions: a case series of burns patients at the Royal Brisbane and Women's Hospital.

Caravan explosions due to gas cylinder explosions or gas leaks are responsible for a small but significantly injured group of burns patients. Those involved in explosions are sometimes assumed to be at risk of primary blast wave injury; however, the likelihood of such injuries is unclear. The aim of this research was to seek evidence of primary blast injury in groups defined by clinicians as having sustained burns in explosive and non-explosive events. This is a single-centre case series of patients with caravan-related burns from 2009 to 2019, identified using the burns data registry at the Royal Brisbane and Women's Hospital. Patients were divided into two groups based on the mechanism of injury, with injuries sustained from either a gas bottle explosion (group 1) or from gas ignition (group 2). Twenty-one patients were identified over the 10-year period. The explosion group suffered more extensive burns, with a median % total body surface area of 31% (23.5-43.5) and 9.5% (5-20) in group 1 and group 2, respectively (P = 0.01). There was a numerically longer median hospital and intensive care unit length of stay in group 1. In multivariable analysis, there were no statistically significant predictors of intensive care unit or hospital length of stay. None of the patients appeared to have suffered any of the expected effects of primary blast wave injury. Gas bottle explosions in caravans uncommonly, if ever, result in a blast wave of sufficient energy to cause primary blast injury.