Medical Intensive Care Unit Research Articles

Consensus statements for the establishment of medical intensive care in low-resource settings: international study using modified Delphi methodology

BackgroundThe inadequacy of intensive care medicine in low-resource settings (LRS) has become significantly more visible after the COVID-19 pandemic. Recommendations for establishing medical critical care are scarce and rarely include expert clinicians from LRS.MethodsIn December 2023, the National Association of Intensivists from Bosnia and Herzegovina organized a hybrid international conference on the topic of organizational structure of medical critical care in LRS. The conference proceedings and literature review informed expert statements across several domains. Following the conference, the statements were distributed via an online survey to conference participants and their wider professional network using a modified Delphi methodology. An agreement of ≥ 80% was required to reach a consensus on a statement.ResultsOut of the 48 invited clinicians, 43 agreed to participate. The study participants came from 20 countries and included clinician representatives from different base specialties and health authorities. After the two rounds, consensus was reached for 13 out of 16 statements across 3 domains: organizational structure, staffing, and education. The participants favored multispecialty medical intensive care units run by a medical team with formal intensive care training. Recognition and support by health care authorities was deemed critical and the panel underscored the important roles of professional organizations, clinician educators trained in high-income countries, and novel technologies such as tele-medicine and tele-education.ConclusionDelphi process identified a set of consensus-based statements on how to create a sustainable patient-centered medical intensive care in LRS.

A-324 Performance and Turnaround Time of Plasma Lactate Assay on POCT, Blood Gas Instrument, and Chemistry Analyzer

Abstract Background Time is a critical factor of plasma lactate testing in the management of patients with sepsis. To best serve these patients, we must optimize testing methods to provide a turnaround time (TAT) that guides efficient patient care. Point of care tests (POCTs) provide rapid results for emergency department and medical intensive care unit but are not feasible for all hospital settings. Laboratory testing methods on an automation line provide greater efficiency but result slowly due to need of specimen preparation and longer analytical time. The goal of this study is to provide detailed TATs of plasma lactate testing among the methods of POCT, chemistry analyzer in an automation line, and blood gas analyzer. Methods Plasma lactate testing was performed by three methods, GEM Premier ChemSTAT (POCT in ER only), Beckman AU5800 (chemistry analyzer), and Radiometer ABL800 (blood gas instrument). The TAT of lactate for each method was measured and include the time from specimen collection to laboratory receipt (except for POCT method), and time from specimen receipt to resulting (including specimen preparation for Beckman AU5800). Results The average TATs of lactate testing for each method in all hospital sites are detailed with respect to each event and subcategorized (Table 1). The average TAT of 12.0 min on Radiometer ABL800 is higher than the TAT of 2.5 on GEM Premier ChemSTAT method but is greatly reduced compared to the TAT of 35.4 min on Beckman AU5800. Conclusions Radiometer ABL800 method could be the optimal laboratory method for plasma lactate testing fulfilling the TAT (average 12 min), with less test cancellation due to specimen stability issue, and combines testing with blood gases. Using three Radiometer ABL800 instruments, we manage the performance of around 70 plasma lactate tests daily.

S774 Utilization of Bowel Regimens in the Medical Intensive Care Unit

S774 Utilization of Bowel Regimens in the Medical Intensive Care Unit

Shared Decision-Making Communication and Prognostic Misunderstanding in the ICU

Surrogate misunderstanding of patient survival prognosis in the intensive care unit (ICU) is associated with poor patient and surrogate outcomes. Shared decision-making (SDM) may reduce misunderstanding. To evaluate the association between SDM-aligned communication and prognostic misunderstanding. This retrospective cohort study was conducted at 13 medical and surgical ICUs at 5 hospitals in North Carolina, Pennsylvania, and Washington between December 2012 and January 2017. Participants were surrogates of adult patients receiving prolonged mechanical ventilation and ICU physicians. Analysis was performed May to November 2023. SDM-aligned communication during ICU family meetings, defined as the presence of high-quality serious illness communication behaviors aligned with SDM principles. The primary outcome was postmeeting surrogate prognostic misunderstanding, defined as the absolute difference between the physician's estimate of survival prognosis and the surrogate's perception of that estimate (range, 0-100 percentage points). The secondary outcome was postmeeting physician misunderstanding, defined as the absolute difference between a surrogate's estimate of survival prognosis and the physician's perception of that estimate (range, 0-100 percentage points). Prognostic misunderstanding of 20 percentage points or greater was considered clinically significant as in prior work. Of 137 surrogates, most were female (102 [74.5%]), and there were 22 (16.1%) Black surrogates, 107 (78.1%) White surrogates, and 8 surrogates (5.8%) with other race and ethnicity. Of 100 physicians, most were male (64 [64.0%]), with 11 (11.0%) Asian physicians, 4 (4.0%) Black physicians, and 75 (75.0%) White physicians. Median (IQR) surrogate prognostic misunderstanding declined significantly after family meetings (before: 22.0 [10.0 to 40.0] percentage points; after: 15.0 [5.0 to 34.0] percentage points; P = .002), but there was no significant change in median (IQR) physician prognostic misunderstanding (before: 12.0 [5.0 to 30.0] percentage points; after: 15.0 [5.0 to 29.0] percentage points; P = .99). In adjusted analyses, SDM-aligned communication was not associated with prognostic misunderstanding among surrogates or physicians (surrogates: β = -0.74; 95% CI, -1.81 to 0.32; P = .17; physicians: β = -0.51; 95% CI, -1.63 to 0.62; P = .38). In a prespecified subgroup analysis of 78 surrogates (56.9%) with clinically significant premeeting prognostic misunderstanding, SDM-aligned communication was associated with reduced surrogate postmeeting prognostic misunderstanding (β = -1.71; 95% CI, -3.09 to -0.34; P = .01). In this retrospective cohort study, SDM-aligned communication was not associated with changes in prognostic misunderstanding for all surrogates or physicians, but it was associated with reduced prognostic misunderstanding among surrogates with clinically significant misunderstanding at baseline.

Respiratory Syncytial Virus and US Pediatric Intensive Care Utilization

Bronchiolitis is the most common diagnosis necessitating respiratory support and pediatric intensive care, and respiratory syncytial virus (RSV) is the most common cause of bronchiolitis. In 2023, the monoclonal antibody nirsevimab and the maternal RSVpreF vaccine were implemented to prevent RSV in infants. To determine the potential association of novel RSV prevention strategies with pediatric intensive care unit (ICU) utilization. This retrospective cross-sectional study examined US pediatric ICU encounters with and without RSV from January 1, 2017, to June 1, 2023. Data were from Oracle Cerner RealWorld Data, a national electronic health record database. All children (aged >1 day and <18 years) admitted to an ICU during the study period were included in the analysis. Statistical analysis was performed from February to May 2024. The primary outcomes were ICU encounters with RSV and ICU encounters with RSV eligible for RSV prevention. There were 119 782 ICU encounters from 53 hospitals; 65 757 encounters (54.9%) were male; median (IQR) age was 4.5 (1.1-12.5) years, median (IQR) ICU length of stay was 1.8 (1.0-3.9) days; 13 702 ICU encounters (11.4%) had RSV, of which 38.6% (5217) were eligible for prevention (4.4% of total ICU encounters). Encounters with RSV accounted for 21.1% (109 334) of ICU days, of which 43.8% (47 888) were eligible for prevention (9.2% of total ICU days). Encounters with RSV were associated with a greater use of positive pressure ventilation (4074 [29.7%] vs 18 821 [17.7%]; P < .001) and vasoactive medications (3057 [22.3%] vs 18 570 [17.5%]; P < .001) compared with those without RSV. The findings of this retrospective cross-sectional study of RSV and US pediatric intensive care utilization suggest that if 65% to 85% of eligible children received RSV prevention, an estimated 2.1% to 2.8% reduction in pediatric ICU encounters and an estimated 4.5% to 5.9% reduction in pediatric ICU days could be achieved.

Application of metabolic phase-specific modified nutrition risk in critically ill score: a prospective observational study in critically ill patients.

The prevalence of malnutrition in intensive care units (ICU) is high and can be caused by poor intake or absorption of nutrients in the digestive track, as well as disease-related inflammation. As strong catabolism restricts nutrient supply and potentially leads to subsequent malnutrition, appropriate nutrition should be provided based on the metabolic status. However, nutritional support strategies for considering the metabolic phase are not well established. Therefore, this study aimed to establish a strategy for nutritional support in each phase by implementing a phase-specific modified Nutrition Risk in Critically Ill (mNUTRIC) score. This prospective observational study was conducted on all adult patients admitted to the medical ICU for at least 36 h at Seoul National University Bundang Hospital between September 2020 and September 2022. Patient nutrition assessment (mNUTRIC score), clinical information, and nutritional supply (calories and proteins) were measured twice, in the acute phase (measured at 2 days) and late phase (measured at 7 days). The relationship between nutritional supply and 28-day mortality was analyzed using multiple logistic regression according to the mNUTRIC score in the acute and late phases. Risk factors related to 28-day mortality were analyzed using univariate and multivariate Cox proportional hazards regressions. Of the 631 patients admitted to the ICU during the study period, 613 were included in the acute phase and 361 patients were included in the late phase. Nutritional supply was associated with 28-day mortality, with high mNUTRIC scores in both the acute and late phases. Cox proportional hazards regression analysis demonstrated that a high mNUTRIC score [hazard ratio (HR) 3.20 and 2.52, respectively], lactate >2.5 mg/dL were independent risk factors in both the acute and late phases. In addition, Albumin <2.5 mg/dL, the presence of neoplasm, and the need for dialysis in the acute phase, calorie adequacy <0.7 in the late phase (HR, 2.19) were identified as additional risk factors. The mNUTRIC score is a suitable tool for identifying critically ill patients who benefit from nutritional support. Nutritional supply should be considered for patients with high mNUTRIC scores in both the acute and late phases; however, careful supply should be provided in the acute phase and sufficient supply should be provided in the late phase.

Developing Augmented Pro-SOFA and Pro-SAPS Models by Integrating Biomarkers PCT, NLR, and CRP with SOFA and SAPS-III Scores.

Sepsis, a life-threatening condition characterized by a dysregulated immune response to infection, remains a significant clinical challenge globally. This study aims to enhance the predictive accuracy of existing sepsis severity scores by developing augmented versions of the SOFA and SAPS-III models, termed Pro-SOFA and Pro-SAPS, through the integration of biomarkers procalcitonin (PCT), neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP). This prospective observational study was conducted in the medical ICU of a tertiary care hospital in southern India from August 2022 to December 2023. A total of 301 adult patients suspected or confirmed to have sepsis were assessed for eligibility, with 171 patients completing the study. Demographic and clinical data were collected; SOFA and SAPS-III scores were calculated and augmented with PCT, NLR, and CRP to develop Pro-SOFA and Pro-SAPS models. The performance of these models was evaluated using Brier scores, AUC, and net reclassification index (NRI). The augmented Pro-SOFA and Pro-SAPS models demonstrated superior predictive accuracy compared to their original counterparts. The Brier scores for Pro-SOFA and Pro-SAPS were 0.181 and 0.165, respectively, indicating better calibration than the original scores. The Pro-SAPS showed significant improvement over the original SAPS-III score (NRI = 0.50, SE = 0.14, p < 0.01). Similarly, Pro-SOFA outperformed the original SOFA (NRI = 0.49, SE = 0.13, p < 0.01). Integrating PCT, CRP, and NLR with SOFA and SAPS-III scores to develop Pro-SOFA and Pro-SAPS significantly improves the predictive accuracy for sepsis mortality and can thus potentially improve sepsis outcomes. Nandakumar A, Sudeep S, Sreemohan AC, Vijayakumar S, Sudhakaran GJ, Gutjahr G, et al. Developing Augmented Pro-SOFA and Pro-SAPS Models by Integrating Biomarkers PCT, NLR, and CRP with SOFA and SAPS-III Scores. Indian J Crit Care Med 2024;28(10):935-941.

Characterization of Ganciclovir Dosing for the Management of Cytomegalovirus in Solid Organ Transplant Recipients Receiving Sustained Low-Efficiency Dialysis.

The optimal dosing of intravenous ganciclovir in patients receiving sustained low-efficiency dialysis (SLED) remains unclear. The primary objective is to characterize the dosing of ganciclovir for treating and preventing cytomegalovirus (CMV) in Solid Organ Transplant Recipients receiving SLED. The secondary objective is to evaluate the safety and efficacy of the dosing practices described in this study. Retrospective review of electronic medical records from solid organ transplant recipients (SOTRs) admitted to the Medical Surgical Intensive Care Unit at the Toronto General Hospital (TGH) between November 28, 2016, and September 1, 2021, was conducted. Patients concurrently receiving ganciclovir and SLED were included. Among the 27 encounters for CMV prevention, 18 patients underwent 8-hour SLED, 6 underwent 24-hour SLED, and 3 received other SLED durations. Most patients (80%) on 8-hour SLED began ganciclovir at 2.5 mg/kg/d, whereas 80% of those on 24-hour SLED started at 5 mg/kg/d. No breakthrough viremia occurred at 5 mg/kg/d, with 1 instance at 2.5 mg/kg/d. Cytopenia rates were higher at 5 mg/kg/d (33% vs 20%). For treatment (n = 20), 16 patients underwent 8-hour SLED, 2 underwent 24-hour SLED, and 2 underwent 12-hour SLED. Most (75%) on 8-hour SLED started at 2.5 mg/kg/d, whereas all on 24-hour SLED began at 5 mg/kg/d. Viral eradication rates were 75% and 60% at 2.5 and 5 mg/kg/d, respectively, with higher cytopenia rates at 5 mg/kg/d (37.5% vs 0%). Dose adjustments were primarily in response to refractory disease or cytopenia. At our institution, ganciclovir dosing patterns suggest that for patients requiring 8-hour SLED, there is clinician comfort in using 2.5 mg/kg/d for prevention and 5 mg/kg/d for treatment. In 24-hour SLED, 5 mg/kg/d may be considered for prevention. Higher doses may be considered for CMV treatment; however, we found greater variability in the dosing practices for these patients. Further research with larger sample sizes and ganciclovir drug-level assessments is needed to optimize dosing strategies for CMV treatment.

The importance of high total body water/fat free mass ratio and serial changes in body composition for predicting hospital mortality in patients with severe pneumonia: a prospective cohort study

PurposeThis study aimed to investigate the impact of body composition variables on hospital mortality compared to other predictive factors among patients with severe pneumonia. Additionally, we aimed to monitor the dynamic changes in body composition variables over the course on days 1, 3, and 8 after intensive care unit (ICU) admission for each patient.MethodsWe conducted a prospective study, enrolling patients with severe pneumonia admitted to the medical intensive care unit at Kaohsiung Chang Gung Memorial Hospital from February 2020 to April 2022. We collected clinical data from all patients and assessed their body composition at 1, 3, and 8 days post-ICU admission. On day 1, we analyzed clinical and body composition variables to predict in-hospital mortality.ResultsMultivariate analysis identified the Modified Nutrition Risk in the Critically Ill (mNUTRIC) score and the ratio of total body water to fat-free mass (TBW/FFM) as independent factors associated with in-hospital mortality in severe pneumonia patients. Receiver operating characteristic analysis determined that the TBW/FFM ratio was the most reliable predictive parameter of in-hospital mortality, with a cutoff value of 0.74. General linear regression with repeated measures analysis showed that hospital non-survivors displayed notable fluctuations in body water, fat, and muscle variables over the course of days 1, 3, and 8 after ICU admission.ConclusionsThe mNUTRIC score and TBW/FFM ratio emerged as independent factors for predicting hospital mortality, with the TBW/FFM ratio demonstrating the highest reliability as a predictive parameter.

Serum Adiponectin Is Elevated in Critically Ill Patients with Liver Disease and Associated with Decreased Overall Survival.

Adiponectin, an adipokine with anti-inflammatory properties, has been implicated in various liver diseases. This study aimed to elucidate the prognostic value of serum adiponectin levels in critically ill patients with liver disease. This observational study included 161 critically ill patients admitted to the medical ICU of RWTH Aachen University Hospital due to acute liver failure or decompensated advanced chronic liver disease. Serum adiponectin levels were measured at ICU admission and after 48 h. Clinical parameters and outcomes, including transplant-free survival, were analyzed. Serum adiponectin concentrations were significantly elevated compared to healthy controls (p < 0.001). Levels were particularly high in patients with sepsis compared to those with gastrointestinal bleeding as the precipitating factor of acute decompensation (p = 0.045) and were higher in female patients (p = 0.023). Adiponectin concentrations correlated with the Model of End-Stage Liver Disease (MELD) score and Child-Pugh score. Multivariate analysis confirmed a significant correlation with total bilirubin (r = 0.292, p < 0.001) and serum sodium (r = -0.265, p = 0.028). Higher adiponectin concentrations were associated with a trend towards poorer 30- and 180-day survival. Cox regression analysis identified a significant association between increased adiponectin concentration and reduced transplant-free survival (p = 0.037), supported by a Kaplan-Meier analysis using a cutoff of 119 ng/mL (log-rank 5.145, p = 0.023). Elevated serum adiponectin concentrations are associated with liver dysfunction and poor outcomes in critically ill patients. Higher adiponectin levels at ICU admission may predict poorer transplant-free survival. Further research in larger, multicenter cohorts is warranted to validate these findings and explore the underlying mechanisms.

Comparison of Traumatic Brain Injury in Adult Patients with and without Facial Fractures.

Facial fractures and associated traumatic brain injuries represent a worldwide public health concern. Therefore, we aimed to determine the pattern of brain injury accompanying facial fractures by comparing adult patients with and without facial fractures in terms of demographic, clinical, and imaging features. This single-center, retrospective study included 492 polytrauma patients presenting at our emergency department from January 2019 to July 2023, which were divided in two groups: with facial fractures (FF) and without facial fractures (non-FF). The following data were collected: age, sex, mechanism of trauma (road traffic accident, fall, and other causes), Glasgow Coma Scale (GCS), the evolution of the patient (admitted to a medical ward or intensive care unit, neurosurgery performed, death), and imaging features of the injury. Data were analyzed using descriptive tests, Chi-square tests, and regression analyses. A p-value less than 0.05 was considered statistically significant. In the FF group, there were 79% (n = 102) men and 21% (n = 27) women, with a mean age of 45 ± 17 years, while in the non-FF group, there were 70% (n = 253) men and 30% (n = 110) women, with a mean age 46 ± 17 years. There was a significant association between brain injuries and facial fractures (p < 0.001, AOR 1.7). The most frequent facial fracture affected the zygoma bone in 28.1% (n = 67) cases. The most frequent brain injury associated with FF was subdural hematoma 23.4% (n = 44), and in the non-FF group, the most common head injury was intraparenchymal hematoma 29% (n = 73); Conclusions: Both groups shared similarities regarding gender, age, cause of traumatic event, and outcome but had significant differences in association with brain injuries, ICU admission, and clinical status.

Identifying optimal serum 1,3-β-D-Glucan cut-off for diagnosing Pneumocystis Jirovecii Pneumonia in non-HIV patients in the intensive care unit

BackgroundSerum (1,3)-β-D-glucan (BDG) detection for diagnosis of Pneumocystis jirovecii pneumonia (PJP) in non-human immunodeficiency virus (HIV) immunocompromised patients lacks intensive care unit (ICU)-specific data. We aimed to assess its performance and determine the optimal cutoff for PJP in ICU population.MethodsThis retrospective study included critically ill non-HIV immunocompromised patients admitted to a medical ICU with suspected pneumonia, undergoing simultaneous microbiological testing for P. jirovecii on lower respiratory tract specimens and serum BDG. Confounders affecting BDG positivity were explored by multivariable logistic regression. Optimal cut-offs were derived from Youden’s index for the entire cohort and subgroups stratified by confounders. Diagnostic performance of serum BDG was estimated at different cutoffs.ResultsOf 400 patients included, 42% were diagnosed with PJP and 58.3% had positive serum BDG. Serum BDG’s area under the receiver operating characteristic curve was 0.90 (0.87–0.93). At manufacturer’s 150 pg/ml cut-off, serum BDG had high sensitivity and negative predictive value (94%), but low specificity and positive predictive value (67%). Confounders associated with a positive serum BDG in PJP diagnosis included IVIG infusion within 3 days (odds ratio [OR] 9.24; 95% confidence interval [CI] 4.09–20.88, p < 0.001), other invasive fungal infections (OR 4.46; 95% CI 2.10–9.49, p < 0.001) and gram-negative bacteremia (OR 29.02; 95% CI 9.03–93.23, p < 0.001). The application of optimal BDG cut-off values determined by Youden’s index (252 pg/ml, 390 pg/ml, and 202 pg/ml) specific for all patients and subgroups with or without confounders improved the specificity (79%, 74%, and 88%) and corresponding PPV (75%, 65%, and 85%), while maintaining reasonable sensitivity and NPV.ConclusionsTailoring serum BDG cutoff specific to PJP and incorporating consideration of confounders could enhance serum BDG’s diagnostic performance in the ICU settings.

SARS-CoV2 pneumonia patients admitted to the ICU: Analysis according to clinical and biological parameters and the extent of lung parenchymal lesions on chest CT scan, a monocentric observational study

Background CT-scan and inflammatory and coagulation biomarkers could help in prognostication of COVID-19 in patients on ICU admission. Objective The objectives of this study were to measure the prognostic value of the extent of lung parenchymal lesions on computed tomography (CT) and of several coagulation and inflammatory biomarkers, and to explore the characteristics of the patients depending on the extent of lung parenchymal lesions. Design Retrospective monocentric observational study achieved on a dataset collected prospectively. Setting Medical ICU of the university hospital of Clermont-Ferrand, France. Patients All consecutive adult patients aged ≥18 years admitted between 20 March, 2020 and 31 August, 2021 for COVID-19 pneumonia. Interventions Characteristics at baseline and during ICU stay, and outcomes at day 60 were recorded. The extent of lung parenchyma lesions observed on the chest CT performed on admission was established by artificial intelligence software. Measurements Several clinical characteristics and laboratory features were collected on admission including plasma interleukin-6, HLA-DR monocytic–expression rate (mHLA-DR), and the extent of lung parenchymal lesions. Factors associated with day-60 mortality were investigated by uni- and multivariate survival analyses. Results 270 patients were included. Inflammation biomarkers including the levels of neutrophils, CRP, ferritin and Il10 were the indices the most associated with the severity of the extent of the lung lesions. Patients with more extensive lung parenchymal lesions (≥ 75%) on admission had higher CRP serum levels. The extent of lung parenchymal lesions was associated with a decrease in the PaO2/FiO2 ratio(p&lt;0.01), fewer ventilatory-free days (p = 0.03), and a higher death rate at day 60(p = 0.01). Extent of the lesion of more than 75% was independently associated with day-60 mortality (aHR = 1.72[1.06; 2.78], p = 0.03). The prediction of death at day 60 was improved when considering simultaneously biological and radiological markers obtained on ICU admission (AUC = 0.78). Conclusions The extent of lung parenchyma lesions on CT was associated with inflammation, and the combination of coagulation and inflammatory biomarkers and the extent of the lesions predicted the poorest outcomes.

Outbreak caused by multidrug-resistant OXA-48 and NDM-1 producing Klebsiella pneumoniae inthe intensive care unit of a cancer hospital.

We report a nosocomial outbreak caused by a multidrug-resistant carbapenemase-producing Klebsiella pneumoniae (MDRCPKp), that was detected in six patients admitted to the medical intensive care unit between 20th of December 2023 and 15th of January 2024 in Ankara, Turkey. The investigation of this outbreak was started on 29th of December 2023. During the outbreak 11 samples were collected from the six patients with MDRCPKp. Pulsed-field gel electrophoresis (PFGE) was performed to determine the genetic relatedness and clonality of MDRCPKp strains. MDRCPKp was isolated in the tracheal aspiration culture, blood, urine, and screening samples. Five patients with MDRCPKp colonization developed healthcare-associated infection. In one patient MDRCPKp was isolated from tracheal aspirate and the screening cultures were considered as colonization not infection. PFGE analysis revealed that all isolates belonged to the same K. pneumoniae clone. MDRCPKp strain of this outbreak exhibited multidrug resistance and co-produced OXA-48 and NDM-1. This outbreak ended after application of strict infection control measures. An outbreak of MDRCPKp can occur in hospitals, especially in the intensive care units; thus, it should be detected early by infection control teams. A strong collaboration between infection control team and microbiology laboratory is essential to cope with MDR bacterial outbreaks in hospitals.

Clinical vs. autopsy diagnostic discrepancies in the intensive care unit: a systematic review and meta-analysis of autopsy series.

The aim of this study was to assess whether there is a discrepancy between clinical and autopsy-based diagnoses in adult intensive care unit (ICU) patients. We conducted a systematic review of cohort studies reporting on conventional autopsy-confirmed missed diagnoses. The discrepancy rate was per study calculated by dividing the number of patients with a missed diagnosis by the number of autopsies. Missed diagnoses were classified according to the Goldman classification as 'major' and 'minor' with major missed diagnoses further differentiated into Class I missed diagnoses (i.e., diagnoses that may have altered therapy or survival) and Class II missed diagnoses (i.e., diagnoses that would not have altered therapy or survival). Class I missed diagnoses constitute the primary outcome of interest. Pooled estimates for discrepancy rates (95% confidence intervals) were calculated using a mixed-effects logistic regression model with 'study' as random effect. Meta-regression was used to assess relationships between major discrepancy rates and autopsy rates, start year of study, and ICU type. Forty-two studies were identified totaling 6305 analyzed autopsies and 1759 patients with missed diagnoses. The pooled discrepancy rates for Class I and major missed diagnoses were 6.5% (5-8.5) and 19.3% (15.3-24), respectively. Meta-regression analysis revealed that autopsy rate was inversely associated with discrepancy rate. Class I discrepancy rates did not change over time. Burn and trauma ICUs had lower discrepancy rates as compared to medical ICUs, possibly because of higher autopsy rates. Missed diagnoses remain common in ICUs. A higher autopsy rate does not reveal more major diagnostic errors. These data support a clinically driven autopsy policy rather than a systematic autopsy policy.

A Multi-step Integrative Workflow Implementation to Improve Documentation of Point of Care Ultrasound in Medical Intensive Care Unit.

Point of care ultrasound (POCUS) provides quick bedside assessment for diagnosing and managing life-threatening conditions in critical care medicine. There has been increasing interest in developing infrastructure to archive images, record clinical interpretation, assess quality, and recoup revenue for POCUS. We present a simple workflow by systems integration of electronic medical record, ultrasound machines, picture archiving, and communication system to facilitate POCUS documentation and billing. We recorded a trend on the number of POCUS performed before and after introduction of the structured integration. We observed and recorded a linear increase over time post-intervention. Our innovative and integrated POCUS workflow is an effective way to document and bill POCUS.

Deranged Liver Biochemistry in a Non-Liver Intensive Care Unit: A Prospective Study

Introduction: Common indications for admission to a liver intensive care unit (LICU) are often due to complications of an underlying chronic liver disease or to an acute insult to the liver either by bacterial or viral infections, alcohol or drugs. Secondary or acquired liver injury occurs in patients with systemic disease in patients who are admitted to a non-LICU setting. These patients are often hemodynamically unstable with multiorgan failure. The aim of the study was to understand the pattern of liver injury in patients admitted to a non-LICU for issues unrelated directly to the liver. Materials and Methods: Patients admitted to medical, neuro and cardiac ICU of the institution were included. All patients had liver biochemistry at admission. R factor (RF) criteria (alanine aminotransferase: S. Alkaline phosphatase ratio) was used for stratifying the liver injury as hepatocellular (HC) (RF-HC; ≥5), cholestatic (RF-C; ≤2) and mixed type (RF-HC+C; 2–5). Patients were followed up in the ICU until discharge. Statistical Analysis: SPSS v26 (IBM Corp.) was used for analysis. Chi-square test was done for categorical variables and Fisher’s exact test, when the expected frequency in the contingency table was &lt;5 in more than 25% of the cells. P &lt; 0.05 was considered as statistically significant. Results: 108 (43.9%) of 246 admissions had liver injury (43.9%). The elevation in liver enzymes were &lt;2 times the upper limit of normal range. There were no significant differences in enzyme elevations in the 3 ICUs. The most common type of liver injury was RF-C (67; 62%) followed by RF-HC+C (34; 31.5%) and RF-HC (7; 6.48%). There was no difference in the disease specific liver injury. Patients with RF-C needed significantly more inotrope support (P = 0.001); 76% survived (P = 0.023). Those with RF-HC required hemodialysis (P = 0.001) with poor survival outcome (42.9%). Conclusions: Liver enzymes are not significantly elevated in non-LICU patients. RF criteria is useful in not only predicting the type of liver injury but also predicting the likely outcome.

Early surgical outcome for Tetralogy Of Fallot In An African Setting; A Tanzanian experience using retrospective analysis of hospital data

BackgroundTetralogy of Fallot (TOF) is typically treated in infancy but often done late in many resource-limited countries, jeopardizing surgical outcomes. This study examined the early results of children undergoing primary complete TOF repair at the Jakaya Kikwete Cardiac Institute (JKCI) in Tanzania, an emerging cardiac center in Eastern Africa.MethodsA retrospective cohort study of children ≤ 18 years undergoing primary TOF complete repair between 2019 and 2021 was conducted. Patients with complex TOF and those with obvious genetic syndrome were excluded. Data on socio-demography, pre-and postoperative cardiac complications, Intensive Care Unit (ICU) and hospital stay, and in-hospital and 30-day mortality were analyzed. Logistic regressions were employed to find the factors for mortality, ICU, and hospital stays.ResultsThe I02 children underwent primary TOF complete repair were majority male (65.7%; n = 67), with a median age of 3.0 years (IQR: 2–6), ranging from 3 months to 17 years.Only 20 patients (19.6%) were below one year of age. Almost all (90%; n = 92) were underweight, with a mean BMI of 14.6 + 3.1 kg/m2 Haematocrits were high, with a median of 48.7 (IQR: 37.4–59.0). The median oxygen saturation was 81% (IQR:72–93). Over a third of patients (38.2%; n = 39) needed Trans annular patch (TAP) during surgery. The median ICU stay was 72 h (IQR:48–120), with ICU duration exceeding three days for most patients. The median hospital stay was 8.5 days (IQR:7–11), with 70 patients (68.2%)experiencing an extended hospital stay of > 7 days. Bacterial sepsis was more common than surgical site infection (5.6%; n = 6 vs. 0.9%;n = 1). No patient needed re-operation for the period of follow up. The in-hospital mortality rate was 5.9%, with no deaths occurring in children less than one year of age nor after discharge during the 30-day follow-up period. No statistically significant differences were observed in outcomes in relation to age, sex, levels of hematocrit and saturations, presence of medical illnesses, and placement of TAP.ConclusionTOF repairs in this African setting at a national cardiac referral hospital face challenges associated with patients’ older age and compromised nutritional status during the surgery. Perioperative mortality rates and morbidity for patients operated at an older age remain elevated. It’s important to address these issues to improve outcomes in these settings.

Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal in the Medical Intensive Care Unit (ICU): A Retrospective Cohort Study.

Background: Phenobarbital (PHB) is a safe and efficacious alternative to benzodiazepines (BZD) for treating severe alcohol withdrawal (AWS). However, the safety of utilizing PHB for patients initially treated with BZD is unknown. Objective: To evaluate the safety and efficacy of PBH compared to BZDs in severe AWS in the medical intensive care unit (ICU). Methods: This was a retrospective cohort study comparing critically ill patients admitted for AWS who received BZDs or PHB. The primary outcome was time to persistent resolution of altered mentation. Secondary outcomes included development and duration of delirium, need for mechanical ventilation, development of withdrawal seizures, and ICU and hospital length of stay. Results: Ninety-five patients were evaluated (53 in PHB group, 42 in BZD group). Before study medication, less BZD patients demonstrated abnormal mentation compared with PHB patients (RASS < -2: 2.39% vsvs. 28.12%, respectively, and RASS > +2: 9.9% vsvs. 48.76%; P <0.001 for both). No difference was seen between groups for the primary outcome (1.8 hours for BZD cohort vsvs. 13.81 hours for PHB cohort; P =0.22). More patients in the BZD cohort developed a seizure after study medication administration (5.67% vs 0%, respectively; P =0.02). No significant difference was seen in other secondary outcomes. Conclusions: This study provides support for use of PHB after BZD if patients remain in uncontrolled withdrawal. Despite significant doses of BZDs before PHB, patients in the PHB cohort demonstrated similar clinical and safety outcomes compared to BZD alone.

Inability to Sit-to-Stand in Medical ICUs Survivors: When and Why We Should Care.

To investigate the prevalence and association with mortality of inability to perform sit-to-stand independently in critically ill survivors 3 months following medical ICU (MICU) discharge. Prospective cohort study. Six MICUs at a tertiary care hospital. MICU survivors who could sit-to-stand independently before the index hospitalization. None. Inability to sit-to-stand (yes/no) was measured at four points following MICU discharge: upon ICU discharge, 1, 2, and 3 months afterward. Mortality was evaluated at 6- and 12-month post-MICU discharge. Among 194 participants, 128 (66%) had inability to sit-to-stand upon MICU discharge. Recovery occurred, with rates decreasing to 50% at 1 month, 38% at 2 months, and 36% at 3 months post-MICU discharge, plateauing at 2 months. Inability to sit-to-stand at 3 months was significantly associated with 21% mortality at 12 months and a 4.2-fold increased risk of mortality (adjusted hazard ratio, 4.2; 95% CI, 1.61-10.99), independent of age, Sequential Organ Failure Assessment score, and ICU-acquired weakness. Notably, improvement in sit-to-stand ability, even from "totally unable" to "able with assistance," correlates with reduced mortality risk. Inability to sit-to-stand affects about 36% of MICU survivors even at 3 months post-ICU discharge, highlighting rehabilitation challenges. Revisiting sit-to-stand ability post-ICU discharge is warranted. Additionally, using sit-to-stand as a screening tool for interventions to improve return of its function and mortality is suggested.