Medical Intensive Care Unit Patients Research Articles

The Use of a Checklist to Optimize Electrolyte Replacement in the ICU.

Electrolyte replacement protocols are routinely used in intensive care units (ICU) to guide magnesium replacement. Guided by serum levels, these protocols include no patient-specific factors despite a literature showing ICU patients routinely have significant deficits despite normal serum levels. The authors developed a checklist to help identify patients requiring more aggressive magnesium replacement than the electrolyte replacement protocol would provide. The checklist included risk factors for having significant magnesium deficits and for developing arrhythmias. The checklist was retrospectively applied to 364 medical ICU patients. Diabetic patients prescribed outpatient diuretics were defined as the highest-risk population. A total of 88% of patients in this subgroup had normal magnesium levels. Despite averaging 3.4 risk factors per patient, only 3 of 32 patients received magnesium. Applying the checklist would have suggested additional repletion for at least 85% of patients. A checklist can help identify ICU patients who may require more aggressive magnesium supplementation than protocols will provide.

Comparison of Neutrophil Lymphocyte Ratio combined SOFA versus APACHE IV in assessing the Prognosis of Sepsis Patients admitted to Medical Intensive Care Unit

Background Sepsis poses a significant threat in the Medical Intensive Care Unit (MICU), with high morbidity and mortality rates. Accurate prognostic tools are essential for guiding patient management. This study aims to compare the effectiveness of Neutrophil–Lymphocyte Ratio with Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) in predicting sepsis outcomes. A prospective cross-sectional design will enrol septic MICU patients, collecting baseline data and scoring systems. Patient outcomes, including mortality and length of MICU stay, will be analyzed using correlation and ROC curve analyses. This study addresses the current gap in direct comparisons of these tools. Results The results of this study are anticipated to reveal significant correlations between the Neutrophil Lymphocyte Ratio combined with SOFA and APACHE IV scores and patient outcomes. Specifically, we expected to observe strong associations between the combined scoring system and mortality rates, length of MICU stay, and the need for organ support. Furthermore, we anticipate that the Neutrophil Lymphocyte Ratio combined with SOFA will demonstrate higher predictive accuracy than APACHE IV to assess prognosis in sepsis patients admitted to the MICU. Conclusion Based on the results obtained from this prospective cross-sectional study, we can draw conclusions regarding the comparative effectiveness of NLR (Neutrophil Lymphocyte Ratio) combined with SOFA and APACHE IV in assessing the prognosis of sepsis in the MICU. We anticipate that the combined scoring system will provide a more accurate prognostic assessment and enable healthcare professionals to make well-informed choices regarding patient care and the distribution of resources. These findings will contribute to building evidence on sepsis and may have implications for improving patient outcomes in the MICU setting.

Comparison of Daily versus Admission and Discharge Surveillance Cultures for Multidrug-Resistant Organism Detection in an Intensive Care Unit.

Admission and discharge screening of patients for asymptomatic gut colonization with multidrug-resistant organisms (MDROs) is a traditional approach to active surveillance, but its sensitivity for detecting colonization is uncertain. Daily rectal or fecal swab samples and clinical data were collected over 12 months from patients in one 25-bed intensive care unit (ICU) in Chicago, IL USA and tested for the following multidrug-resistant organisms (MDROs): vancomycin-resistant enterococci (VRE); third-generation cephalosporin-resistant Enterobacterales, including extended-spectrum β-lactamase-producing Enterobacterales (ESBL); and carbapenem-resistant Enterobacterales (CRE). MDRO detection by (1) admission/discharge surveillance cultures or (2) clinical cultures were compared to daily surveillance cultures. Samples underwent 16S rRNA gene sequencing to measure the relative abundance of operational taxonomic units (OTUs) corresponding to each MDRO. Compared with daily surveillance cultures, admission/discharge cultures detected 91% of prevalent MDRO colonization and 63% of incident MDRO colonization among medical ICU patients. Only a minority (7%) of MDRO carriers were identified by clinical cultures. Higher relative abundance of MDRO-associated OTUs and specific antibiotic exposures were independently associated with higher probability of MDRO detection by culture. Admission and discharge surveillance cultures underestimated MDRO acquisitions in an ICU. These limitations should be considered when designing sampling strategies for epidemiologic studies that use culture-based surveillance.

Critical care management of acute intoxications, dynamics and changes over time: a cohort study.

Acute intoxications and poisonings are a relevant cause for ICU admission of critically ill patients. This study aimed to determine the characteristics of intoxicated patients in a tertiary center medical ICU in Austria over time and to investigate parameters associated with ICU mortality. This study was a retrospective data analysis including adult ICU patients from the years 2007 to 2021. In addition to ICU documentation, pre-hospital, and emergency department documents as well as autopsy reports were utilized. In an exploratory subanalysis, we compared these findings to a historical dataset from our facility from 1992 to 1996. We identified 581 cases admitted to the medical ICU because of acute poisoning (2007-2021), of which 45% were female and 46.6% were mixed intoxications. Suicidal intent was the primary cause of intoxication (48.2%) and ICU length of stay was median 1.2days. The majority of deceased patients received pre-hospital mechanical CPR. Primary and secondary poison/toxin removal modalities were used in 29.9% and 11.7% of cases, whereas antidotes were administered in 54.4%. Comparing the data with a historical cohort (n = 168), we found a shift in primary detoxification away from gastric lavage and an increase in alternative secondary poison/toxin removal techniques. The ICU mortality was 4.1% and 4.2% in the present and historic cohort, respectively. Pre-existing psychiatric illnesses increased from 49% in the historic to 69% in the present cohort. Psychiatric illness predisposes patients to severe intoxications necessitating ICU care, thus increasing prevention measures seems warranted. Females did present with a different spectrum of intoxications compared to males. ICU mortality remained low over time and most deceased patients had a grim prognosis already on ICU arrival.

Malnutrition and pectoralis muscle index in medical intensive care unit patients: A matched cohort study.

Muscle assessment is an important component of nutrition assessment. The Global Leadership Initiative on Malnutrition (GLIM) consortium recently underscored the need for more objective muscle assessment methods in clinical settings. Various assessment techniques are available; however, many have limitations in clinical populations. Computed tomography (CT) scans, obtained for diagnostic reasons, could serve multiple purposes, including muscle measurement for nutrition assessment. Although CT scans of the chest are commonly performed clinically, there is little research surrounding the utility of pectoralis muscle measurements in nutrition assessment. The primary aim was to determine whether CT-derived measures of pectoralis major cross-sectional area (PMA) and quality (defined as mean pectoralis major Hounsfield units [PMHU]) could be used to identify malnutrition in patients who are mechanically ventilated in an intensive care unit (ICU). A secondary aim was to evaluate the relationship between these measures and clinical outcomes in this population. A retrospective analysis was conducted on 33 pairs of age- and sex-matched adult patients who are being mechanically ventilated in the ICU. Patients were grouped by nutrition status. Analyses were performed to determine differences in PMA and mean PMHU between groups. Associations between muscle and clinical outcomes were also investigated. Compared with nonmalnourished controls, malnourished patients had a significantly lower PMA (P = 0.001) and pectoralis major (PM) index (PMA/height in m2; P = 0.001). No associations were drawn between PM measures and clinical outcomes. These findings regarding CT PM measures lay the groundwork for actualizing the GLIM call to action to validate quantitative, objective muscle assessment methods in clinical settings.

Post-intensive cardiac care outpatient long-term outreach clinic (PICCOLO clinic): Defining health care needs and outcomes among coronary care unit survivors

ObjectivePatients who survive critical illness endure complex physical and mental health conditions, referred to as post-intensive care syndrome (PICS). The University of Michigan's post-intensive cardiac care outpatient long-term outreach (PICCOLO) clinic is designed for patients recently admitted to the coronary care unit (CCU). The long-term goal of this clinic is to understand post-CCU patients' needs and design targeted interventions to reduce their morbidity and mortality post-discharge. As a first step toward this goal, we aimed to define the post-discharge needs of CCU survivors. Design, setting, particpantsWe retrospectively reviewed case-mix data (including rates of depression, PTSD, disability, and cognitive abnormalities) and health outcomes for patients referred to the PICCOLO clinic from July 1, 2018, through June 30, 2021 at Michigan Medicine. ResultsOf the 134 referred patients meeting inclusion criteria, 74 (55 %) patients were seen in the PICCOLO clinic within 30 days of discharge. Patients seen in the clinic frequently screened positive for depression (PHQ-2 score ≥3, 21.4 %) and cognitive impairment (MOCA <26, 38.8 %). Further, patients also reported high rates of physical difficulty (mean WHODAS 2.0 score 28.4 %, consistent with moderate physical difficulty). Consistent with medical intensive care unit (ICU) patients, CCU survivors experience PICS. ConclusionThis work highlights the feasibility of an outpatient care model and the need to leverage information gathered from this care model to develop treatment strategies and pathways to address symptoms of PICS in CCU survivors, including depression, cognitive impairment, and physical disability.

Association between nutritional risk status and both diaphragmatic dysfunction and diaphragm atrophy in medical ıntensive care unit patients.

Aim: critical illness often leads to malnutrition and diaphragmatic dysfunction (DD), common in intensive care units (ICU). Ultrasonography (US) is a potent tool for detecting DD. This study examines the connection between malnutrition risk and DD in ICU patients using ultrasonographic diaphragm measurements in medical ICU patients. Methods: we assessed nutritional risk using risk screening tools and mid-upper arm circumference measurements (MUAC). Diaphragm atrophy (DA) and DD were evaluated by measuring diaphragmatic excursion (DE), thickness, and thickening fraction (TF) by US. We then compared these diaphragmatic measurements in patients based on their nutritional risk scores. Results: of the fifty patients studied, 54 % to 78 % were at risk of malnutrition, 28 % exhibited diaphragm atrophy (DA), and 24 % showed DD upon ICU admission. Malnutrition risk diagnosed by all nutritional risk screening tools was significantly more frequent in patients with DD, while diagnosed by MUAC was considerably higher in patients with DA. A total of 16 patients (32 %) died during their ICU stay, with DD, DA, and malnutrition risks (as identified by the mNUTRIC Score) being more prevalent among non-survivors (p < 0.05). Malnutrition risk (as determined by the mNUTRIC Score) was an independent risk factor for DD [OR (95 % CI): 6.6 (1.3-34), p = 0.03]. Conclusion: malnutrition risk may be significantly associated with DD and DA in medical ICU patients upon ICU admission.

Evaluation of cardiovascular drugs in medical intensive care unit patients: A prospective observational study

Background: Nowadays, due to various factors such as stress, the number of patients suffering from cardiovascular disease particularly acute attacks of myocardial infarction (MI) and other CVS conditions is increasing. As the number of patients with CVS disease increases, the evaluation of various CVS drugs used in intensive care unit plays a very important role in improving the rationality of prescription as well as the quality of treatment. Aims and Objectives: The aims and objectives are to study the various cardiovascular drugs prescribed for patients admitted in the medical intensive care unit of a tertiary care teaching hospital, Udaipur, Rajasthan. Materials and Methods: It was a prospective and observational study conducted from August 2021 to March 2023. The required data were obtained from the patient’s prescription after obtaining consent. The prior permission was obtained from the institutional ethics committee of the college. Results: Nine hundred and thirty-six patients who fulfilled the inclusion criteria were studied. Among 936, 217 patients suffered from CVS disorders. 916 CVS drugs including antihypertensive drugs were prescribed for patients. Diabetes (26.40%) is the most common comorbidity found. Around 50.23% of patients were of MI. Noradrenaline (10.89%), atorvastatin (1.089%), furosemide (9.83%), and aspirin (6.30%) were the most commonly prescribed medications among inotropes, hypolipidemic, diuretics, and anti-platelet groups, respectively. Conclusion: After studying the various aspects, it was concluded that the cardiovascular health of the people in general is at stake of risk which may be due to lifestyle, stress, etc. The pharmaco-epidemiological studies should be conducted so that rational prescribing practices can be promoted.

Pharmacological interventions used to control hyperglycemia in surgical and medical intensive care unit patients in a tertiary care hospital

Background: Hyperglycemia with or without diabetes is associated with increased morbidity and mortality in critically ill patients. The management practices to control hyperglycemia vary widely and often do not conform to standard guidelines. Aim and Objective: The aim of the study was to find out various pharmacological interventions used to manage hyperglycemia, frequency, and characteristics of drug-induced hypoglycemic episodes, and factors associated with BGLs at or above 180 mg/dL. Material and Methods: This prospective observational study was conducted in a tertiary care hospital on 369 adult patients admitted in medical or surgical intensive care unit and suffering from hyperglycemia. The pharmacological interventions used to control hypoglycemia, characteristics of drug-induced hypoglycemic episodes, and factors associated with blood glucose level (BGL) at or above 180 mg/dL were evaluated. Result: About 43% of patients received no pharmacological intervention, in 33% of patients basal bolus insulin was used while oral antidiabetic agents were used in 7.3% of patients. Blood glucose was maintained within a target range of 140–180 mg/dL on 45.6% patient-days. Basal bolus insulin was linked to hypoglycemia in 85.7% of hypoglycemic episodes. Previous history of diabetes, use of 0.45% dextrose normal saline, beta-blockers, and statins were associated with BGL above 180 mg/dL. Conclusion: Management of hyperglycemia in ICU patients is less than optimal.

Amyloid-β and caspase-1 are indicators of sepsis and organ injury.

Sepsis is a life-threatening condition that results from a dysregulated host response to infection, leading to organ dysfunction. Despite the prevalence and associated socioeconomic costs, treatment of sepsis remains limited to antibiotics and supportive care, and a majority of intensive care unit (ICU) survivors develop long-term cognitive complications post-discharge. The present study identifies a novel regulatory relationship between amyloid-β (Aβ) and the inflammasome-caspase-1 axis as key innate immune mediators that define sepsis outcomes. Medical ICU patients and healthy individuals were consented for blood and clinical data collection. Plasma cytokine, caspase-1 and Aβ levels were measured. Data were compared against indices of multiorgan injury and other clinical parameters. Additionally, recombinant proteins were tested in vitro to examine the effect of caspase-1 on a functional hallmark of Aβ, namely aggregation. Plasma caspase-1 levels displayed the best predictive value in discriminating ICU patients with sepsis from non-infected ICU patients (area under the receiver operating characteristic curve=0.7080). Plasma caspase-1 and the Aβ isoform Aβx-40 showed a significant positive correlation and Aβx-40 associated with organ injury. Additionally, Aβ plasma levels continued to rise from time of ICU admission to 7 days post-admission. In silico, Aβ harbours a predicted caspase-1 cleavage site, and in vitro studies demonstrated that caspase-1 cleaved Aβ to inhibit its auto-aggregation, suggesting a novel regulatory relationship. Aβx-40 and caspase-1 are potentially useful early indicators of sepsis and its attendant organ injury. Additionally, Aβx-40 has emerged as a potential culprit in the ensuing development of post-ICU syndrome.

Effects of a multilevel intervention of resistance training with or without beta-hydroxy-beta-methylbutyrate in medical ICU patients during entire hospitalisation: a four-arm multicentre randomised controlled trial

BackgroundIntensive care unit-acquired weakness (ICU-AW) is a prevalent and severe issue among ICU patients. Resistance training and beta-hydroxy-beta-methylbutyrate (HMB) intervention have demonstrated the potential to enhance muscle function in patients with sarcopenia and in older adults. The purpose of this study was to determine whether resistance training and/or HMB administration would improve physical function, muscle strength, and quality of life in medical ICU patients.MethodsIn this multicentre, four-arm, single-blind randomised control trial, a total of 112 adult patients with internal medical diagnoses admitted to the ICU were enrolled. These participants were then randomly assigned to one of four treatment groups: the resistance training group received protocol-based multilevel resistance exercise, the HMB group received 3 g/day of HMBCa, combination group and control groups received standard care, from the ICU to the general ward until discharge. The primary outcomes assessed at discharge included six-minute walking distance (6MWD) and short physical performance battery (SPPB). Secondary outcomes measured included muscle mass, MRC score, grip strength, and health reports quality of life at different time points. Data analysis was performed using a generalised linear mixed model, adhering to the principles of intention-to-treat analysis.ResultsResistance training and combination treatment groups exhibited significant increases in SPPB scores (3.848 and 2.832 points, respectively) compared to the control group and substantial improvements in 6WMD (99.768 and 88.577 m, respectively) (all with P < 0.01). However, no significant changes were observed in the HMB group. Muscle strength, as indicated by MRC and grip strength tests conducted at both ICU and hospital discharge, showed statistically significant improvements in the resistance training and combination groups (P < 0.05). Nevertheless, no significant differences were found between the treatment groups and usual care in terms of 60-day mortality, prevalence of ICU-AW, muscle mass, quality of life, or other functional aspects.ConclusionsResistance training with or without beta-hydroxy-beta-methylbutyrate during the entire hospitalisation intervention improves physical function and muscle strength in medical ICU patients, but muscle mass, quality of life, and 60-day mortality were unaffected.Trial registrationChiCTR2200057685 was registered on March 15th, 2022.

Genetic association studies in critically ill patients: protocol for a systematic review

IntroductionPatients in the intensive care unit (ICU) are highly heterogeneous in characteristics, their clinical course, and outcomes. Genetic variability may partly explain the variability and similarity in disease courses observed among critically ill patients and may identify clusters of subgroups. The aim of this study is to conduct a systematic review of all genetic association studies of critically ill patients with their outcomes.Methods and analysisThis systematic review will be conducted and reported according to the HuGE Review Handbook V1.0. We will search PubMed, Embase, and the Cochrane Library for relevant studies. All types of genetic association studies that included acutely admitted medical and surgical adult ICU patients will be considered for this review. All studies will be selected according to predefined selection criteria, evaluated and assessed for risk of bias independently by two reviewers. Risk of bias will be assessed according to the HuGE Review Handbook V1.0 with some modifications reflecting recent insights. We will provide an overview of all included studies by reporting the characteristics of the study designs, the patients included in the studies, the genetic variables, and the outcomes evaluated.Ethics and disseminationWe will use data from peer-reviewed published articles, and hence, there is no requirement for ethics approval. The results of this systematic review will be disseminated through publication in a peer-reviewed scientific journal.Systematic review registrationPROSPERO CRD42021209744.

Delirium in critical care unit patients: prevalence and associated risk factors

A large number of critically ill patients experience physical and mental distress, resulting from systemic illness, multiple interventions, and environmental factors, during their stay in the Intensive Care Unit (ICU). Delirium is a common medical problem related to prolonged critical care. ICU delirium is linked to higher mortality as well as morbidity. The majority of patients suffering from delirium in the ICU experience hypoactive delirium, which remains relatively undiagnosed. Multiple tools have been devised for ICU delirium screening and early diagnosis. This short report aimed to assess the prevalence of delirium using a validated screening tool in medical ICU patients and determine the associated modifiable and non-modifiable risk factors. Keywords: Psychomotor agitation, Anxiety, Delirium, critical illness.

2956. Increased Microbiota Alpha Diversity is Associated with Decreased Hospital Mortality in Medical Intensive Care Unit Patients

Abstract Background Characteristics of the gut microbiome may be useful to predict resistance to colonization and expansion of pathogenic organisms such as C. difficile. In this study, we evaluated whether inclusion of microbiome characteristics improved a clinical prediction model for in-hospital mortality. Methods Rectal or fecal swab samples were collected daily from medical intensive care unit (ICU) patients from three hospitals between 2017-2019 and underwent 16S rRNA gene sequencing of the V4 region. Patient admissions with ≥1 rectal swab collected &amp;lt; 48hrs from ICU admission were randomly selected 2:1 for calibration and validation analyses. Independent variables included Shannon Index, Microbiome Health Index, Community Type (CT) and relative abundance (RA) of specific bacterial taxa based on 3% sequence difference or class-level classification. The RA of each bacterial taxon was range-standardized (95%) and scaled to analyze a 10% relative difference within each taxon’s range. Logistic regression models identified microbiome characteristics at admission that were associated with in-hospital mortality. Fixed effects were included in all models to account for microbiome differences between facilities. Results There were 1365 patient admissions (910 calibration, 455 validation) analyzed (Table), of which 134 (96 calibration, 38 validation) died during hospitalization. Increase in Shannon Index by 1 [OR 0.66 (0.51-0.84), p=0.001], 10% relative increase in the RA of Bacilli [OR 1.15 (1.08-1.22), p&amp;lt; 0.001] and 10% relative increase in the RA of Enterococcus [OR 1.10 (1.04-1.14), p=0.001] were associated with in-hospital mortality in calibration models after controlling for Charlson Comorbidity Index [OR 1.23 (1.15-1.32), p&amp;lt; 0.001]. Increase in Shannon Index by 1 [OR 0.88 (0.57-1.38), p=0.581] had the same direction and similar odds in the validation cohort (Figure), supporting the findings of the calibration model. Conclusion In this secondary analysis of a large, multicenter, prospective medical ICU cohort, we found that higher alpha diversity of the gut microbiome was associated with decreased odds of in-hospital mortality. Disclosures Michael Z. David, MD PhD, Covance: Grant/Research Support|GSK: Advisor/Consultant|GSK: Grant/Research Support Erik R. Dubberke, MD, MSPH, Abbott: Advisor/Consultant|AstraZeneca: Advisor/Consultant|Ferring Pharmaceuticals: Advisor/Consultant|Ferring Pharmaceuticals: Grant/Research Support|Merck and Co.: Advisor/Consultant|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Seres Therapeutics: Advisor/Consultant|Summit: Advisor/Consultant|Theriva Biologics: Grant/Research Support Vincent B. Young, MD/PhD, ASM: Senior Editor|Debiopharm: Advisor/Consultant|Vedanta Biosciences: Advisor/Consultant

852. Epidemiology, clinical characteristics and outcomes of invasive pulmonary aspergillosis among critically ill patients in medical intensive care unit: A retrospective study from the tertiary care hospital in Thailand

Abstract Background Invasive pulmonary aspergillosis (IPA) is a serious infection which leads to poor outcomes particularly in immunocompromised patients. Recently, IPA in critically ill patients in intensive care unit (ICU) has been increasingly recognized owing to its substantial morbidity and mortality. However, clinical data of IPA in ICU is scarce especially in Thailand. Methods A single-center, retrospective, observational study was conducted in King Chulalongkorn Memorial Hospital. We collected data on demographic, clinical characteristics, and outcomes of the patients who developed IPA during admission in the medical intensive care unit (MICU) between Jan 2016 to Dec 2021. IPA was identified by using ICD-10 and medication code for voriconazole, amphotericin B or liposomal amphotericin B. Patients met proven, probable IPA according to EORTC/MSG definition or putative IPA were included. The primary outcome was the incidence of IA in the MICU. Clinical characteristics, 12-week all-cause mortality and associated risk factor were the secondary outcomes. Results During the study period, a total of 5,019 patients were admitted in MICU. Fifty-seven met definitions of IPA which represented incidence of 1.14%. Seven patients (12.3%) had proven IPA, while 37 (61.4%) and 13 (22.8%) patients had probable and putative IPA, respectively. Cardiovascular disease (33.3%), chronic liver disease (26.7%), and diabetes (20.0%) were common comorbidities in patients with putative IPA. Diagnosis was made at median of 5 (3-10) days after ICU admission. Organisms were identified in 36 patients (63%) which Aspergillus fumigatus was the most common species (36.8%). All-cause mortality at week 12 was 89.5%. SOFA score (OR 1.494, 95%CI 1.058-2.110) and vasopressor used on admission (OR 16.00, 95%CI 2.209-115.92) had trend toward increase mortality. Median survival in putative and probable IPA group were 4 and 8 days after diagnosis (p= 0.023). Patients who received treatment with voriconazole had median survival 13 days compared to 5 days in other antifungal agents (p= 0.006). Conclusion IPA carried a high mortality among critically ill patients in MICU. High SOFA score and vasopressors used at the MICU admission were associated with mortality. Voriconazole therapy appeared to correlate with longer survival time. Disclosures All Authors: No reported disclosures

Prolonged use of neuromuscular blocking agents is associated with increased long-term mortality in mechanically ventilated medical ICU patients: a retrospective cohort study

BackgroundNeuromuscular blockade agents (NMBAs) can be used to facilitate mechanical ventilation in critically ill patients. Accumulating evidence has shown that NMBAs may be associated with intensive care unit (ICU)-acquired weakness and poor outcomes. However, the long-term impact of NMBAs on mortality is still unclear.MethodsWe conducted a retrospective analysis using the 2015–2019 critical care databases at Taichung Veterans General Hospital, a referral center in central Taiwan, as well as the Taiwan nationwide death registry profile.ResultsA total of 5709 ventilated patients were eligible for further analysis, with 63.8% of them were male. The mean age of enrolled subjects was 67.8 ± 15.8 years, and the one-year mortality was 48.3% (2755/5709). Compared with the survivors, the non-survivors had a higher age (70.4 ± 14.9 vs 65.4 ± 16.3, p < 0.001), Acute Physiology and Chronic Health Evaluation II score (28.0 ± 6.2 vs 24.7 ± 6.5, p < 0.001), a longer duration of ventilator use (12.6 ± 10.6 days vs 7.8 ± 8.5 days, p < 0.001), and were more likely to receive NMBAs for longer than 48 h (11.1% vs 7.8%, p < 0.001). After adjusting for age, sex, and relevant covariates, the use of NMBAs for longer than 48 h was found to be independently associated with an increased risk of mortality (adjusted HR: 1.261; 95% CI: 1.07–1.486). The analysis of effect modification revealed that this association was tended to be strong in patients with a Charlson Comorbidity Index of 3 or higher.ConclusionsOur study demonstrated that prolonged use of NMBAs was associated with an increased risk of long-term mortality in critically ill patients requiring mechanical ventilation. Further studies are needed to validate our findings.

Abstract 13261: Global T Wave Inversion: Incidence and Implications in Critically Ill Patients

Background: Symmetric global T-wave inversion (GTWI) occurs in 0.3% of general hospital admits. As reported by Walder and Spodick, GTWI exhibited a 4:1 female preponderance and was often associated with ACS or central nervous system (CNS) disorders; in-hospital mortality was not affected. Anecdotally we have observed this ECG pattern in critically-ill medical ICU (MICU) patients. We hypothesized that GTWI is more prevalent among MICU patients and may be associated with adverse outcomes. Methods: We reviewed the ECGs, demographic, clinical, and physiological data of 1652 consecutive patients admitted to 2 medical ICUs. Those admitted to CCU and Neuro ICU were excluded as were MICU patients with a primary diagnosis of ACS, acute CNS syndrome, LBBB, ventricular pacing, pre-excitation, and uninterpretable ECG. ECGs performed within 48 hours of ICU admit were reviewed by 2 blinded readers. GTWI was defined by the criteria of Walder and Spodick. The GTWI group was compared to 95 matched patients without GTWI. Results: See Table. GTWI occurred in 75 patients (4.5%); 56% of whom were female. Significant differences between GTWI vs control included history of CAD (p=0.03), cardiomyopathy (p=0.035), CKD (p=0.046), and prior EP procedure (p=0.023). In addition, QT-interval (p&lt;0.0001), QTc (p&lt;0.0001) and BNP (1433±1725 vs 750±978 pg/mL; p=0.032) were greater in the GTWI group. LVEF (52.7±16.2% vs 55.6±14.1%) and cTnI (1.35±2.52 vs 1.25±4.15 pg/mL) were similar. MICU days and APACHE II score were greater in those with GTWI. Total length of stay and in-hospital mortality were similar. Conclusions: In this critically-ill MICU cohort, GTWI was more prevalent compared to previously reported general hospital admits. A distinct female preponderance was not found. This ECG pattern was associated with underlying cardiac disease, greater length of MICU stay and higher illness severity, but was not associated with higher in-hospital morality.

Stewardship-Guided T2Candida Testing Shortens Time to Antifungal Treatment and Reduces Antifungal Usage Among Medical Intensive Care Unit Patients With Septic Shock.

Diagnosis of invasive candidiasis (IC) is limited by insensitivity and slow turnaround of cultures. Our objectives were to define the performance of T2Candida, a nonculture test, under guidance of a diagnostic stewardship program, and evaluate impact on time to antifungal initiation and antifungal utilization. This was a retrospective study of adult medical intensive care unit (MICU) patients with septic shock for whom T2Candida testing was performed from March 2017 to March 2020. Patients with positive T2Candida results during this period were compared to MICU patients who did not undergo T2Candida testing but had septic shock and blood cultures positive for Candida from January 2016 through March 2020. Overall, 155 T2Candida tests from 143 patients were included. Nine percent of T2Candida tests were positive compared to 4.5% of blood cultures. Sensitivity, specificity, positive predictive value, and negative predictive value of T2Candida for proven and probable IC were 78%, 95%, 50%, and 99%, respectively. Patients who tested positive for T2Candida (n = 14) were diagnosed earlier and initiated on antifungal therapy sooner than patients with IC (n = 14) diagnosed by blood culture alone (median, 5.6 vs 60 hours; P < .0001). Median antifungal days of therapy/1000 patient-days were 23.3/month preimplementation and 15/month postimplementation (P = .007). Following a negative T2Candida result, empiric antifungals were either not administered in 58% or discontinued within 72 hours in 96% of patients. Diagnostic stewardship guided T2Candida testing resulted in reduced time to IC diagnosis, faster initiation of antifungal therapy, and lower antifungal usage among MICU patients with septic shock.

Prognostic Significance of the Strong Ion Gap in Patients in Medical and Surgical Intensive Care Units.

Background This study aimed to analyze acid-base imbalance by assessing the arterial blood gas (ABG) samples of the medical and surgical intensive care unit (ICU) patients by the Stewart approach and demonstrate the advantages of this method in delineating the acid-base status in cases where Henderson-Hasselbalch, anion gap, and base excess cannot optimally depict the imbalance and create recognition in the clinicians in this regard. Methodology Adult (i.e., age > 18 years) patients admitted to the ICU of our institution during a one-year study period were included in this study. The patients were divided into two groups based on the indication of admission to the ICU as medicalor surgical. The ABG, sodium, potassium, calcium, magnesium, phosphate, chloride, albumin, lactate, hemoglobin, hematocrit, leukocyte, blood urea nitrogen, and creatinine values determined during the first 24-hour period were used for calculating the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE II), strong ion difference apparent (SIDa), and SID effective (SIDe) scores, which were subsequently compared between the groups. Results Overall, 220 (110 medical and 110 surgical) patients were included. The mean patient age was 63.56 ± 18.08 years. The mean APACHE II scores were 21.99 and 19.63 in the medical and surgical groups, respectively. Overall, 110 patients died, while 110 were referred to the regular patient floor. The mean APACHE II score of the patients who died was 28.3, and the latter group had a mean APACHE II score of 13.57. There was a significant difference between the surgical and medical patient groups regarding mean values of APACHE II, SIDa, and SIDe scores. Also, the differences were significant between the patients who died and were discharged. There was a significant difference between the patients who died and were discharged regarding the strong ion gap (SIG); however, the medical and surgical patient groups were not different concerning the SIG values. Conclusions We conclude that SIDa, SIDe, and SIG can be used in medical and surgical ICU patients to predict prognosis.

The influence of continuous renal replacement therapy on 1,3-β-d-glucan levels in critically ill patients: a single-center retrospective propensity score study

1,3-β-d-Glucan (BDG) is commonly used for diagnosing invasive fungal infections (IFIs). While exposure to cellulose-based hemodialyzers is known to cause false-positive BDG results, the impact of modern hemofilters used in continuous renal replacement therapy (CRRT) remains unclear. This retrospective, single-center cohort study aimed to evaluate the effect of CRRT on BDG levels in critically ill patients. We included adult intensive care unit (ICU) patients with ≥1 BDG measurement between December 2019 and December 2020. The primary outcome was the rate of false-positive BDG results in patients exposed to CRRT compared to unexposed patients. Propensity score analysis was performed to control for confounding factors. A total of 103 ICU patients with ≥1 BDG level were identified. Most (72.8%) were medical ICU patients. Forty patients underwent CRRT using hemofilter membranes composed of sodium methallyl sulfonate copolymer (AN 69 HF) (82.5%) and of polyarylethersulfone (PAES) (17.5%). Among the 91 patients without proven IFI, 31 (34.1%) had false-positive BDG results. Univariable analysis showed an association between CRRT exposure and false-positive BDG results. However, the association between CRRT exposure and false-positive BDG results was no longer significant across three propensity score models employed: 1:1 match (n = 32) (odds ratio (OR) 1.65, p = .48), model-adjusted (n = 91) (OR 1.75, p = .38), quintile-adjusted (n = 91) (OR 1.78, p = .36). In this single-center retrospective analysis, exposure to synthetic CRRT membranes did not independently increase the risk of false-positive BDG results. Larger prospective studies are needed to further evaluate the association between CRRT exposure and false-positive BDG results in critically ill patients with suspected IFI.