Need For Intensive Care Unit Transfer Research Articles

Mid-Regional Pro-Adrenomedullin Can Predict Organ Failure and Prognosis in Sepsis?

Sepsis causes immune dysregulation and endotheliitis, with an increase in mid-regional pro-adrenomedullin (MR-proADM). The aim of the study is to determine an MR-proADM value that, in addition to clinical diagnosis, can identify patients with localized infection or those with sepsis/septic shock, with specific organ damage or with the need for intensive care unit (ICU) transfer and prognosis. The secondary aim is to correlate the MR-proADM value with the length of stay (LOS). In total, 301 subjects with sepsis (124/301 with septic shock) and 126 with localized infection were retrospectively included. In sepsis, MR-proADM ≥ 3.39 ng/mL identified acute kidney injury (AKI); ≥2.99 ng/mL acute respiratory distress syndrome (ARDS); ≥2.28 ng/mL acute heart failure (AHF); ≥2.55 ng/mL Glascow Coma Scale (GCS) < 15; ≥3.38 multi-organ involvement; ≥3.33 need for ICU transfer; ≥2.0 Sequential Organ Failure Assessment (SOFA) score ≥ 2; and ≥3.15 ng/mL non-survivors. The multivariate analysis showed that MR-proADM ≥ 2 ng/mL correlates with AKI, anemia and SOFA score ≥ 2, and MR-proADM ≥ 3 ng/mL correlates with AKI, GCS < 15 and SOFA score ≥ 2. A correlation between mortality and AKI, GCS < 15, ICU transfer and cathecolamine administration was found. In localized infection, MR-proADM at admission ≥ 1.44 ng/mL identified patients with AKI; ≥1.0 ng/mL with AHF; and ≥1.44 ng/mL with anemia and SOFA score ≥ 2. In the multivariate analysis, MR-proADM ≥ 1.44 ng/mL correlated with AKI, anemia, SOFA score ≥ 2 and AHF. MR-proADM is a marker of oxidative stress due to an infection, reflecting severity proportionally to organ damage.

Changes in Ventilation Practices for Bronchiolitis in the Hospital Ward and Need for ICU Transfer over the Last Decade.

There is limited evidence of the potential benefits of the use of high-flow nasal cannula (HFNC) for the management of bronchiolitis in the ward. Our aim is to describe the ventilation trends for bronchiolitis in our hospital along with the introduction of an HFNC ward protocol and to determine the need for respiratory support escalation and transfer to an intensive care unit (ICU). A retrospective analytical observational study of children < 12 months old requiring admission for a first RSV bronchiolitis episode in a single centre from January 2009 to December 2018. The sample was divided into four groups according to the type of respiratory support that would ensure the clinical stability of the infants on admission. A total of 502 infants were recruited. The total number and percentage of patients admitted in the ward grew progressively over time. Simultaneously, there was an increase in HFNC and, paradoxically, an increase in ICU transfers. The risk of failure was higher for those who required HFNC or CPAP for clinical stabilisation in the first 12 h after admission. Moreover, the risk of failure was also higher in children with standard oxygen therapy promptly escalated to HFNC, especially if they had atelectasis/viral pneumonia, coinfections or a history of prematurity. Despite the limitations of a retrospective analysis, our study reflects usual clinical practice and no correlation was found between the usage of HFNC and a shorter length of hospital stay or less time spent on oxygen therapy.

313. Host Protein Biomarkers Predicting Severity of Lung Damage due to COVID-19

BackgroundBiomarkers to predict the severity of lung damage due to COVID-19 are urgently needed to inform management and treatment decisions. Our objective was to investigate the predictive value of host proteins for worsening respiratory failure in one of the by COVID-19 most affected and diverse patient populations in the US.MethodsWe performed a prospective single-center cross-sectional study of 34 adult patients admitted to Montefiore Medical Center in the Bronx, New York, for respiratory symptoms due to PCR-confirmed COVID-19. Exclusion criteria were age < 21, history of prior SARS-CoV-2 infection, and/or underlying severe chronic lung diseases requiring home O2 and/or high dose steroids. We stratified and compared patients by whether they developed worsening respiratory failure, necessitating transfer to the intensive care unit (ICU) during their hospital stay. Using a custom Luminex Assay, we measured hospital admission serum concentrations of 8 host proteins, representing respiratory-associated epithelial (RAGE, SP-D, CC16), endothelial (Ang-2, vWF), and immune pathways (S100A12, ICAM-1, VCAM-1).ResultsExcept for race and WHO COVID-19 scores, demographics, co-morbidities, symptoms, and symptom duration were not statistically significantly different between patients requiring transfer to the ICU (n=15) and non-ICU patients (n=19). Higher log-transformed levels for 5/8 proteins (S100A12, ICAM-1, Ang-2, RAGE, SP-D) showed significant or marginally significant increased cause-specific hazard for ICU transfer (n=15). Estimated cumulative incidence functions further showed a significantly or near significantly increased risk for ICU transfer for patients with above the median values of S100A12 or ICAM-1 (p=0.013), Ang-2 (p=0.056) or RAGE (p=0.077), respectively (Figure 1). Host proteins predicting need for ICU transfer did not correlate strongly with other clinical laboratory markers for COVID-19 severity (CRP, LDH, D-Dimer, Fibrinogen, Ferritin).Figure 1. Patients with above median levels of host protein markers S100A12, ICAM-1, Ang-2, and RAGE have a significantly or near significantly increased risk for severe respiratory failure requiring transfer to the ICU. Comparison of estimated cumulative incidence at 7 days post admission for host protein markers above and below median levels for (A) S10012 (median 96,675 pg/ml); (B) ICAM-1 (median (1,192,277 pg/ml); (C) Ang-2 (median 3463 pg/ml); (D) RAGE (median 6356 pg/ml); and (E) SP-D (median 11,832 pg/ml).ConclusionThese results suggest that host proteins have additional predictive value for the severity of COVID-19-associated lung damage at time of presentation to the hospital.Disclosures Inessa Gendlina, Nothing to disclose

Impact of Acute Confusional State in Patients With COVID-19 and a Predictive Score.

Background: Acute confusional state (ACS) in COVID-19 is shown to be associated with poor clinical outcomes.Methods: We assessed the impact of ACS - defined as a documented deterioration of mental status from baseline on the alertness and orientation to time, place, and person - on inpatient mortality and the need for intensive care unit (ICU) transfer in inpatient admissions with active COVID-19 infection in a single-center retrospective cohort of inpatient admissions from a designated COVID-19 tertiary care center using an electronic health record system. Furthermore, we developed and validated a neurological history and symptom-based predictive score of developing ACS.Results: Thirty seven out of 245 (15%) patients demonstrated ACS. Nineteen (51%) patients had multifactorial ACS, followed by 11 (30%) patients because of hypoxemia. ACS patients were significantly older (80 [70-85] years vs 50.5 [38-69] years, p < 0.001) and demonstrated more frequent history of dementia (43% vs 9%, p < 0.001) and epilepsy (16% vs 2%, p = 0.001). ACS patients observed significantly higher in-hospital mortality (45.9% vs 1.9%, aOR [adjusted odds ratio]: 15.7, 95% CI = 3.6-68.0, p < 0.001) and need for ICU transfer (64.9% vs 35.1%, aOR: 2.7, 95% CI = 1.2-6.1, p = 0.015). In patients who survived hospitalization, ACS was associated with longer hospital stay (6 [3.5-10.5] days vs 3 [2-7] day, p = 0.012) and numerically longer ICU stay (6 [4-10] days vs 3 [2-6] days, p = 0.078). A score to predict ACS demonstrated 75.68% sensitivity and 81.73% specificity at a cutoff of ≥3.Conclusion: A high prevalence of ACS was found in patients with COVID-19 in our study cohort. Patients with ACS demonstrated increased mortality and need for ICU care. An internally validated score to predict ACS demonstrated high sensitivity and specificity in our cohort.

Characteristics and outcomes of diabetic patients with acute exacerbation of COPD.

Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and diabetes mellitus form a special population due to an increased risk of hyperglycemia from the use of corticosteroids. There is limited data regarding specific outcomes in diabetic patients with AECOPD. A retrospective data analysis of adult patients admitted to North Florida Division of the Hospital Corporation of America (HCA Healthcare) with a primary or secondary diagnosis of AECOPD from January 1, 2018, to December 31, 2018. We excluded patients who needed intensive care unit (ICU) care on day 0. Outcomes assessed included length of stay, mortality, and need for ICU transfer after 48h from admission. Characteristics included age, sex, and race, comorbidities such as diabetes mellitus, chronic kidney disease, acute kidney injury, congestive heart failure, and anemia were analyzed. Comparisons were analyzed via binary and multivariate logistic regression models. A total of 3788 patients admitted for AECOPD were included; amongst them, 1356 patients (~36%) had diabetes mellitus. This subset of patients had higher rates of comorbidities. A significant portion of diabetic patients (72%) received intravenous rather than oral steroids, similar to non-diabetic patients. In addition, diabetic patients were more likely to develop acute kidney injury (14.2% vs 8.0%, p < 0.004) and decompensated heart failure (9.2% vs 4.6%, p < 0.001). Diabetic patients had higher length of stay and increased need for ICU transfer. However, diabetes itself did not independently affect length of stay (CI -0.028, 0.479, p = 0.081) when adjusted to comorbidities and patient's characteristics. Moreover, diabetes was independently associated with an increased need for transfer to ICU (Odds ratio 1.9, p = 0.031). The oral route of steroid use was associated with decreased LOS (β coefficient - 0.9, p < 0.001). Diabetes mellitus is independently associated with increased ICU transfers amongst patients hospitalized with AECOPD. The use of oral steroids rather than intravenous steroids was independently associated with decreased length of stay in diabetic and non-diabetic patients. Despite no difference in intravenous vs. oral corticosteroids demonstrated in previous COPD trials, a significant portion of diabetic patients continue to receive intravenous corticosteroids. Further investigation is required to explore these findings.

Phenobarbital Versus Lorazepam for Management of Alcohol Withdrawal Syndrome: A Retrospective Cohort Study.

Introduction Annually, 500,000 episodes of alcohol withdrawal syndrome (AWS) are severe enough to require clinical attention. A symptom-triggered lorazepam regimen remains the standard of care for the management of hospitalized AWS patients. However, phenobarbital has also been shown to be an effective adjunctive therapy for severe AWS, reducing benzodiazepine use in the emergency department (ED) and the intensive care unit (ICU). The purpose of this study is to compare hospital length of stay (LOS) for AWS patients using phenobarbital-based versus lorazepam-based treatment protocols as monotherapy for management of AWS on general medical units.MethodsThis is a retrospective cohort study over a two-year period (March, 2016 to March, 2018), conducted at three hospitals within the St. Joseph Mercy Health System. We included 606 patients with a primary diagnosis of AWS or alcohol intoxication who met our inclusion criteria (543 in the lorazepam cohort and 63 in the phenobarbital cohort). Adjusted comparisons were done using propensity scoring methods. Hospital LOS was set as the primary outcome. Secondary outcomes included all-cause 30-day readmission, alcohol-related 30-day readmission, 30-day ED visits after discharge, and need for ICU transfer during hospital stay.ResultsPatients who received phenobarbital had a statistically significant shorter hospital LOS as compared to patients who received lorazepam (2.8 versus 3.6 days, P < 0.001). Furthermore, the phenobarbital treatment group had statistically significant lower rates of all-cause 30-day readmission (11.11% versus 14.18%, P = 0.020) and 30-day ED visits after discharge (11.11% versus 18.6%, P = 0.015). No statistical significance was detected for alcohol-related 30-day readmission and the need for ICU transfer between the treatment groups.ConclusionThis study suggests that phenobarbital may be a reasonable alternative to lorazepam in the management of AWS patients admitted to general medical units. Larger scale, well-executed, and adequately powered prospective studies and randomized controlled trials are needed to corroborate these findings.

Assessing the need for transfer to the intensive care unit for Coronavirus-19 disease: Epidemiology and risk factors

BackgroundAlthough many patients with coronavirus disease 2019 (Covid-19) require direct admission to the intensive care unit (ICU), some are sent after admission. Clinicians require an understanding of this phenomenon and various risk stratification approaches for recognizing these subjects. MethodsWe examined all Covid-19 patients sent initially to a ward who subsequently required care in the ICU. We examined the timing transfer and attempted to develop a risk score based on baseline variables to predict progressive disease. We evaluated the utility of the CURB-65 score at identifying the need for ICU transfer. ResultsThe cohort included 245 subjects (mean age 59.0 ± 14.2 years, 61.2% male) and 20% were eventually sent to the ICU. The median time to transfer was 2.5 days. Approximately 1/3rd of patients were not moved until day 4 or later and the main reason for transfer (79.2%) was worsening respiratory failure. A baseline absolute lymphocyte count (ALC) of ≤0.8 103/ml and a serum ferritin ≥1000 ng/ml were independently associated with ICU transfer. Co-morbid illnesses did not correlate with eventual ICU care. Neither a risk score based on a low ALC and/or high ferritin nor the CURB-65 score performed well at predicting need for transfer. ConclusionCovid-19 patients admitted to general wards face a significant risk for deterioration necessitating ICU admission and respiratory failure can occur late in this disease. Neither baseline clinical factors nor the CURB-65 score perform well as screening tests to categorize these subjects as likely to progress to ICU care.

Retrospective Analysis of Outcomes in Acute Myeloid Leukemia (AML) Patients Exposed to Intravenous Contrast Prior to Stem Cell Transplantation

Background:Patients with AML are inherently at increased risk of Acute Kidney Injury (AKI) due to multiple reasons including chemotherapy, antibiotics and risk of tumor lysis syndrome (TLS). Prolonged hospital admissions and persistent neutropenia with increased risk of infections necessitate diagnostic testing including computed tomography (CT) scans with contrast. Contrast induced nephropathy (CIN) is a well-known risk of contrast exposure and is a leading cause of hospital acquired AKI. Acute kidney injury is increasingly being recognized as an independent risk factor for survival in patients with hematologic malignancies. To our knowledge, the incidence of CIN in AML patients and its impact on subsequent cancer management has not been studied.Methods:Retrospective chart review of all newly diagnosed AML patients who received inpatient chemotherapy at Seidman Cancer Center from 2004-2017 were included.Out of the 432 patients screened, 223 were excluded as they did not receive any CT imaging. Serum creatinine (S.cr) was documented prior to receiving chemotherapy for induction, consolidation and/or re-induction for relapsed disease. We recorded the highest S.cr during the 2-7 days after undergoing CT with and without contrast, as per the definition of CIN. Outcomes evaluated include hospital length of stay (LOS), transfer to intensive care unit (ICU), need for renal replacement therapy (RRT) and need for changing subsequent management of AML. We also compared the yield of CT without contrast to CT with contrast. Continuous outcomes were evaluated with univariate generalized linear regression models and binary outcomes were evaluated with univariate logistic regression models.Results:Out of the 209 patients included in the study, 255 cycles of chemotherapy were identified where the patient had a diagnostic CT. This includes 191 inductions, 20 consolidations and 39 relapse inductions. Out of the 255 encounters,136 were CT with contrast and 119 without contrast. LOS, transfer to medical ICU, RRT and need for change in AML management was compared in both groups for induction, consolidation and relapse.Baseline characteristics of patients are summarized in Table 1. The co-morbidities contributing to renal dysfunction and concomitant use of nephrotoxic medications were equally prevalent in both groups.Patients with higher creatinine at presentation predominantly had non-contrast CT done (p <0.001). Average length of stay was 36.6 days in non-contrast group compared to 37.0 days in contrast group (p 0.878). There was a slightly increased need for ICU transfer among the patients who received contrast when compared to non contrast group (22 vs 17 days respectively) however this was not statistically significant (p 0.699). There was no significant change in creatinine post contrast exposure compared to the non-contrast group. Interestingly, need for permanent RRT was noticed to be increased in patients who had non-contrast CT compared to the contrast group (4.2% vs 0.7%, respectively). Subsequent treatment change was needed in 9 patients (6.6%) who received contrast and 7 patients (5.9%) in non-contrast group (p 0.822).CT scan was able to yield positive results half the time (50%) in both contrast and non-contrast group. Of note, patients who had non-contrast CT had a slightly higher need for repeat imaging with IV contrast.Conclusion:CT imaging remains the standard of care for diagnosing many of the complications associated with hematologic malignancies such as pulmonary embolus, atypical pulmonary infection and neutropenic enteritis. Patients with AML are prone to develop AKI for numerous reasons. It is important to note that even if it was only a small number of patients who had a need for permanent RRT in our study it was higher in the setting of no contrast exposure, emphasizing the vulnerability of this subgroup of patients to AKI. Even though no permanent unfavorable outcome was associated with IV contrast exposure in our study, any intervention that could potentially increase the risk of AKI still warrants caution and it may be reasonable to start with a non-contrast CT as an initial diagnostic tool. DisclosuresNo relevant conflicts of interest to declare.

A trial of a real‐time Alert for clinical deterioration in Patients hospitalized on general medical wards

With limited numbers of intensive care unit (ICU) beds available, increasing patient acuity is expected to contribute to episodes of inpatient deterioration on general wards. To prospectively validate a predictive algorithm for clinical deterioration in general-medical ward patients, and to conduct a trial of real-time alerts based on this algorithm. Randomized, controlled crossover study. Academic center with patients hospitalized on 8 general wards between July 2007 and December 2011. Real-time alerts were generated by an algorithm designed to predict the need for ICU transfer using electronically available data. The alerts were sent by text page to the nurse manager on intervention wards. Intensive care unit transfer, hospital mortality, and hospital length of stay. Patients meeting the alert threshold were at nearly 5.3-fold greater risk of ICU transfer (95% confidence interval [CI]: 4.6-6.0) than those not satisfying the alert threshold (358 of 2353 [15.2%] vs 512 of 17678 [2.9%]). Patients with alerts were at 8.9-fold greater risk of death (95% CI: 7.4-10.7) than those without alerts (244 of 2353 [10.4%] vs 206 of 17678 [1.2%]). Among patients identified by the early warning system, there were no differences in the proportion of patients who were transferred to the ICU or who died in the intervention group as compared with the control group. Real-time alerts were highly specific for clinical deterioration resulting in ICU transfer and death, and were associated with longer hospital length of stay. However, an intervention notifying a nurse of the risk did not result in improvement in these outcomes.

Early Use of Noninvasive Mechanical Ventilation in Patients with Acute Hypercapnic Respiratory Failure in a Respiratory Ward: A Prospective Study

Background In recent years, the optimal location for noninvasive mechanical ventilation (NIMV) has been a matter of debate. Our aim was to detect the effectiveness of NIMV in acute hypercapnic respiratory failure (AHRF) in respiratory ward and factors associated with failure. Methods 69 patients treated with NIMV in respiratory ward were prospectively evaluated. The success of NIMV was defined as absence of need for intensive care unit (ICU) transfer with patient's dishcarge from hospital (group 1), failure of NIMV was defined as need for ICU transfer (group 2). Results The mean age was significantly higher in group 2. The cause of respiratory failure was COPD in 51 patients, obesity-hypoventilation syndrome in 14 and kyphoscoliosis in 4 patients. NIMV was successful in 55 patients and unsuccessful in 14. There was no significant difference between the two groups for pretreatment pH, PaCO 2 and PaO 2/FiO 2 After 1h and 3h of NIMV there was significant improvement in group 1. After 3h of NIMV, in group 1 respiratory rate was significantly decreased. The pretreatment APACHE II score, respiratory rate, frequency of pneumoniae, associated complication and comorbid disease was significantly higher in group 2. The success rate was higher in patients with good compliance to NIMV. Conclusion NIMV can be succesfully applied in patients with AHRF in respiratory ward. The associated factors with NIMV failure are absence of early improvement in blood gases and respiratory rate, bad compliance to NIMV, older age, presence of associated complication, comorbid disease, pneumonia and high baseline respiratory rate.

Uso precoz de la ventilación mecánica no invasiva en pacientes con insuficiencia respiratoria hipercápnica aguda ingresados en una sala de neumología: estudio prospectivo

Background In recent years, the optimal location for noninvasive mechanical ventilation (NIMV) has been a matter of debate. Our aim was to detect the effectiveness of NIMV in acute hypercapnic respiratory failure (AHRF) in respiratory ward and factors associated with failure. Methods 69 patients treated with NIMV in respiratory ward were prospectively evaluated. The success of NIMV was defined as absence of need for intensive care unit (ICU) transfer with patient's dishcarge from hospital (group 1), failure of NIMV was defined as need for ICU transfer (group 2). Results The mean age was significantly higher in group 2. The cause of respiratory failure was COPD in 51 patients, obesity-hypoventilation syndrome in 14 and kyphoscoliosis in 4 patients. NIMV was successful in 55 patients and unsuccessful in 14. There was no significant difference between the two groups for pretreatment pH, PaCO 2 and PaO 2/FiO 2. After 1 h and 3 h of NIMV there was significant improvement in group 1. After 3 h of NIMV, in group 1 respiratory rate was significantly decreased. The pretreatment APACHE II score, respiratory rate, frequency of pneumoniae, associated complication and comorbid disease was significantly higher in group 2. The success rate was higher in patients with good compliance to NIMV. Conclusion NIMV can be succesfully applied in patients with AHRF in respiratory ward. The associated factors with NIMV failure are absence of early improvement in blood gases and respiratory rate, bad compliance to NIMV, older age, presence of associated complication, comorbid disease, pneumonia and high baseline respiratory rate.