Intensive Care Unit Outcomes Research Articles

Characteristics and outcomes of ICU-admitted COVID-19 patients in the Omicron and Alpha-dominated periods.

Comparing the outcomes of intensive care unit (ICU) admitted COVID-19 patients during the Alpha and Omicron-dominated periods. Patients with critical COVID-19 disease, requiring ICU admission from May to September 2021 and February to August 2022, were enrolled from a single medical center in Northern Taiwan. Clinical demographics, comorbidities, disease severity, and management strategies were recorded. The 28-day mortality from the two periods were compared both in the original and propensity score (PS)-matched cohort. Of 231 patients, 72 (31.2%) were from the Alpha period and 159 (68.8%) from the Omicron period. Patients in the Omicron period were older, had a lower body mass index, more comorbidities, higher disease severities, and increased 28-day mortality (26.4% vs. 13.9%, p=0.035). In multivariable analysis, the Omicron-dominated period was not identified as an independent factor associated with increased 28-day mortality. COVID-19 patients in Alpha- and Omicron-dominated periods had comparable 28-day mortality in PS-matched cohort (12.1% vs. 18.2%, p=0.733). Independent factors associated with 28-day mortality were a lower PF ratio (PF ratio <100, adjusted odds ratio [aOR] 2.68, 95% confidence interval, CI 1.21-5.94), septic shock ([aOR] 2.39, 95% CI 1.12-5.09) and absence of remdesivir ([aOR] 0.36, 95% CI 0.16-0.83). While patients in the Omicron period exhibited greater severity, the variant was not independently linked to higher 28-day mortality in ICU-admitted patients.

Isolation of Candida Species Is Associated with Comorbidities, Prolonged Mechanical Ventilation, and Treatment Outcomes in Surgical ICU Patients, a Cross-Sectional Study

The isolation of Candida may be related to comorbidity, prolonged mechanical ventilation, and survival during intensive care unit (ICU) stay, especially with non-albicans Candida (NAC). To examine the frequency of Candida isolation, associated comorbidities and outcomes in the surgical ICU in Osijek University Hospital, Croatia, the data from the electronic database from May 2016 to 30 June 2023 were analyzed. In a cross-sectional study examining 15,790 microbiological samples, different strains of Candida were observed in 581 samples from 236 patients. The control group (N = 261) was 130 consecutive patients from March to May 2019 and 131 in the same months in 2020 (pre- and post-COVID-19). Comorbidities, duration of mechanical ventilation, and survival were compared. Patients with isolated Candida were more often non-elective and had significantly more heart, kidney, and liver diseases and sepsis than the control group (p &lt; 0.001). The duration of mechanical ventilation was 9.2 [2.2–9.24], 96 [24–146], 160 [19.5–343], and 224 [73.5–510] hours in the controls, in patients with Candida albicans, in patients with NAC, and in patients with ≥2 Candida species isolated, respectively. The mortality was significantly higher (42%) in patients with isolated Candida than in the control group (19%, p &lt; 0.001). In a multivariate analysis adjusted for patients’ age, the Simplified Acute Physiology Score II, days of ICU, and type of admission, only sepsis on admission was an independent predictor of mortality (odds ratio = 2.27).

Biomarkers of cardiohepatic syndrome in the cardiac intensive care unit

Abstract Introduction Non-cardiovascular end-organ dysfunction is an important determinant of outcomes in cardiac intensive care unit (CICU) patients. We examined the association between in-hospital mortality with the severity and extent of admission liver function test (LFT) abnormalities in a heterogeneous CICU population. Purpose We hypothesized that a greater severity or extent of LFT abnormalities would be associated with higher in-hospital mortality. Methods We included consecutive unique adult CICU patients with available data for one or more of the admission LFT values of interest. Admission laboratory values were defined as those closest to CICU admission. We used the NIH Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 to categorize the severity of each LFT abnormality from Grade 0 (normal) to Grade 4 (life-threatening). We defined the extent of LFT abnormality as the number of individual LFTs meeting criteria for CTCAE Grade 1 or greater. The primary outcome of interest was all-cause in-hospital mortality. Odds ratio (OR) and 95% confidence interval (CI) values for in-hospital mortality were estimated using logistic regression, before and after multivariable adjustment. Results Of 12,428 unique CICU patients, 5,144 were excluded due to a lack of available data for any admission LFT values. The remaining 7,284 patients comprised the final study population. Among patients with available data for each individual LFT, abnormal values were present in: AST, 2,743/5,733 (47.8%); ALT 1,576/5,512 (28.6%); ALK 611/3,684 (16.6%); and TB 898/5,155 (17.4%). A total of 864 (11.9%) patients died during hospitalization. In-hospital mortality was higher for patients with one or more LFTs meeting criteria for CTCAE Grade 1 or greater (17.9% vs. 6.4%, adjusted OR 1.54 [1.27-1.86], p &amp;lt;0.001). A stepwise increase in in-hospital mortality was observed with increasing CTCAE grade, both overall (adjusted OR 1.25 per each higher CTCAE grade [1.16-1.34], p &amp;lt;0.001); (Figure 1A), and for each individual LFT (Figure 1B). Conclusion Cardiohepatic syndrome is an important predictor of prognosis in CICU patients, as the extent and severity of LFT abnormalities are strongly associated with in-hospital mortality. This is the first large-scale study to examine the association between the magnitude of hepatic biomarker derangement with in-hospital mortality in unselected CICU patients. Patients with markedly elevated LFT values exhibited the highest risk of in-hospital mortality. This analysis advocates for the inclusion of commonly obtained LFTs in future risk-prediction tools for enhanced prognostication.

Short-term and long-term outcomes of critically ill patients with solid malignancy: a retrospective cohort study.

With the global increase in patients with solid malignancies, it is helpful to understand the outcomes of intensive care unit (ICU) admission for these patients. This study evaluated the risk factors for ICU mortality and the shortand long-term outcomes in patients with solid malignancies who had unplanned ICU admission. This retrospective cohort study included patients with solid malignancies treated at the medical ICU of a single tertiary center in South Korea between 2016 and 2022. Among the 955 patients, the ICU mortality rate was 23.5%. Lung cancer was the most common cancer type (34.2%) and was significantly associated with increased ICU mortality (odd ratio [OR] 1.58, p = 0.030). Higher Sequential Organ Failure Assessment scores at ICU admission (OR 1.11, p < 0.001), the need for mechanical ventilation (OR 6.74, p < 0.001), or renal replacement therapy during the ICU stay (OR 2.49, p < 0.001) were significantly associated with higher ICU mortality. The 1-year survival rate after ICU admission was 29.3%, with a median survival of 37 days for patients requiring mechanical deviaventilation, and 23 days for patients requiring renal replacement therapy. This study showed that critically ill patients with solid malignancies had poor 1-year survival despite relatively low ICU mortality. These findings highlight the need for careful consideration of ICU admission in patients with solid malignancy, and decision-making should be based on an understanding of the expected short- and long-term prognosis of ICU admission after an informed discussion among patients, families, and physicians.

Sedation in the ICU.

AbstractSedation practices are key to improving intensive care unit (ICU) outcomes. Adequate treatment of pain, minimization of sedation, delirium prevention, and improved patient interaction to ensure early rehabilitation and faster ventilator liberation are evidenced-based components of ICU care. Here we review components of appropriate ICU sedation including the use of multicomponent care bundles such as the ABCDEF bundle with a focus on changes in ICU practice that followed the Covid-19 pandemic.

Impact of sleep disturbances on outcomes in intensive care units

BackgroundSleep deprivation is common in intensive care units (ICUs) and may alter respiratory performance. Few studies have assessed the role of sleep disturbances on outcomes in critically ill patients.ObjectivesWe hypothesized that sleep disturbances may be associated with poor outcomes in ICUs.MethodsPost-hoc analysis pooling three observational studies assessing sleep by complete polysomnography in 131 conscious and non-sedated patients included at different times of their ICU stay. Sleep was assessed early in a group of patients admitted for acute respiratory failure while breathing spontaneously (n = 34), or under mechanical ventilation in patients with weaning difficulties (n = 45), or immediately after extubation (n = 52). Patients admitted for acute respiratory failure who required intubation, those under mechanical ventilation who had prolonged weaning, and those who required reintubation after extubation were considered as having poor clinical outcomes. Durations of deep sleep, rapid eye movement (REM) sleep, and atypical sleep were compared according to the timing of polysomnography and the clinical outcomes.ResultsWhereas deep sleep remained preserved in patients admitted for acute respiratory failure, it was markedly reduced under mechanical ventilation and after extubation (p < 0.01). Atypical sleep was significantly more frequent in patients under mechanical ventilation than in those breathing spontaneously (p < 0.01). REM sleep was uncommon at any time of their ICU stay. Patients with complete disappearance of REM sleep (50% of patients) were more likely to have poor clinical outcomes than those with persistent REM sleep (24% vs. 9%, p = 0.03).ConclusionComplete disappearance of REM sleep was significantly associated with poor clinical outcomes in critically ill patients.

Intensive care unit admission rates and factors associated following Autologous stem cell transplantation-real-world experience from a tertiary center in rural India.

Infectious and other complications can necessitate admission to the intensive care unit (ICU) in autologous stem cell transplantation (ASCT). Data on need for ICU care, impact of various pre- and peri-transplant characteristics on requirement of ICU care and outcomes are scarce from the developing world. A retrospective case record review of ASCT cases was conducted. Pre- and peri-transplant characteristics like infection within 4weeks of transplant, mucositis, surveillance culture positivity, peri-transplant infections, comorbidity, and time to neutrophil and platelet engraftment were noted. A total of 109 patients underwent 109 ASCTs. Most common diagnosis was the plasma cell disorder in 75 (69%) patients. Forty-eight (45%) patients had peri-transplant infections. Fifteen (14%) patients had infections with multi-drug resistant (MDR) organisms. Fifteen (14%) patients required ICU care, the most common reason being hypotension in nine patients (8.3%). Four patients (3.7%) required non-invasive ventilation, and one (0.9%) required invasive ventilation. Mortality rate was 1.8% (two patients). Factors associated with the need for ICU care were time to platelet engraftment (median 15days among those required ICU care versus 13days who did not, p = 0.04) and presence of peri-transplant infection showed a trend toward ICU care need (19% among those required ICU care versus 7% in those who did not, p = 0.05). Delayed platelet engraftment was associated with the need for ICU care and peri-transplant infections were associated with a trend toward need for ICU care.

8091 Clinical Features Associated with ICU Admission and Mortality in Thyroid Storm and Impending Thyroid Storm

Abstract Disclosure: E.D. Zhang: None. I. Hussain: None. Introduction: Thyroid storm is a rare, life-threatening manifestation of thyrotoxicosis characterized by a clinical syndrome of acute multi-organ failure, which can result in significant morbidity and mortality. Impending thyroid storm is a stage of thyrotoxicosis that may progress to thyroid storm if untreated. The aim of this study was to evaluate the demographics and outcomes of patients with thyroid storm at our institution and determine the clinical features associated with severe complications and mortality. We also evaluated the differences in clinical features and outcomes in patients diagnosed with impending thyroid storm versus thyroid storm. Methods: This was a retrospective single-center cohort study evaluating patients aged 18 years or older who were clinically diagnosed with thyroid storm or impending storm at two affiliated tertiary academic centers from 2008-2021. A search of the electronic medical record system using ICD-10 codes for thyroid storm identified patient charts which were reviewed for eligibility. Results: This study included 121 admissions, with 75 (62.0%) patients with thyroid storm and 46 (38.0%) patients with impending thyroid storm. Our study cohort was notably more racially and ethnically diverse than prior U.S. studies with 5.0% non-Hispanic White, 52.9% Black, 33.9% Hispanic, and 8.3% Asian patients. The mortality rate was 4.7%, with all patient deaths occurring in the thyroid storm group. Multivariable logistic regression analysis showed atrial fibrillation (OR 4.09, 95% CI 1.21, 13.85, p=0.02) and acute respiratory failure (OR 22.18, 95% CI 2.29, 215.19, p=0.008) to be significantly associated with a composite outcome of intensive care unit (ICU) admission or death. Comparison of impending storm and thyroid storm groups showed fever (p=0.02), acute respiratory failure (p=0.03), and ICU admission (p=0.02) to be significantly different between groups. Conclusions: This study describes the largest published single-center cohort of patients treated for thyroid storm in the United States. Furthermore, our study contributes importantly to the data for racial/ethnic minorities who are under-represented in prior studies. The mortality rate in this study is lower than most recent studies. The presence of atrial fibrillation and acute respiratory failure were noted to be significantly associated with a composite outcome of ICU admission or death, and the five fatal cases had high rates of cardiac arrest and shock. These findings suggest that complications involving cardiopulmonary compromise are clinically important in predicting severe disease and poor outcomes. Acute respiratory failure was also noted to be significantly different between impending storm and thyroid storm groups indicating that while not currently included in existing diagnostic systems, it is an important complication of thyroid storm that may have prognostic value. Presentation: 6/2/2024

Improving Outcomes for ICU Family Members: The Role of Spiritual Care.

Having a family member hospitalized in the intensive care unit (ICU) can be a stressful experience for family members, encompassing both psychological and spiritual distress. With over 5 million ICU admissions annually in the United States, it is imperative to enhance the experiences and coping mechanisms of ICU family members. In particularly challenging situations, some family members even face psychological effects known as post-intensive care syndrome-family, which includes anxiety, depression, and posttraumatic stress. The distress may be worsened when patients and families experience poor communication or medical care, which has been shown to be more common among minoritized populations including Black and Hispanic patients and families. Family members' emotional and spiritual distress also has an effect on the medical decisions they make for the patient. While research has delved into the impact of spiritual care for ICU family members, further investigation is still needed to determine the most effective approaches for delivering such care. This narrative review will describe a conceptual model aimed at guiding future research in this endeavor. The model proposes that chaplains provide emotional, spiritual, and information support to ICU family members. This affects both their ICU experience, decision making, and outcomes for the patient and family. This process is also affected by characteristics of the family such as race, ethnicity, and economic status. This model helps identify gaps in research, including the need for randomized trials of spiritual care that identify mechanisms underlying outcomes and demonstrate impact of spiritual care, and consider race, ethnicity, and other characteristics.

Extended versus Standard Proning Duration for COVID-19-associated Acute Respiratory Distress Syndrome: A Target Trial Emulation Study.

Rationale: Prone positioning for ⩾16 hours in moderate-to-severe acute respiratory distress syndrome (ARDS) improves survival. However, the optimal duration of proning is unknown. Objectives: To estimate the effect of extended versus standard proning duration on patients with moderate-to-severe coronavirus disease (COVID-19) ARDS. Methods: Data were extracted from a five-hospital electronic medical record registry. Patients who were proned within 72 hours of mechanical ventilation were categorized as receiving extended (⩾24 h) versus standard (16-24 h) proning based on the first proning session length. We used a target trial emulation design to estimate the effect of extended versus standard proning on the primary outcome of 90-day mortality and secondary outcomes of ventilator liberation and intensive care unit (ICU) discharge. Analytically, we used inverse probability of treatment weighted (IPTW) Cox or Fine-Gray regression models. Results: A total of 314 patients were included; 234 received extended proning, and 80 received standard-duration proning. Patients who received extended proning were older, had greater comorbidity, were more often at an academic hospital, and had shorter time from admission to mechanical ventilation. After IPTW, characteristics were well balanced. Unadjusted 90-day mortality in the extended versus standard proning groups was 39% versus 58%. In doubly robust IPTW analyses, we found no significant effects of extended versus standard proning duration on mortality (hazard ratio [95% confidence interval], 0.95 [0.51-1.77]), ventilator liberation (subdistribution hazard, 1.60 [0.97-2.64], or ICU discharge (subdistribution hazard, 1.31 [0.82-2.10]). Conclusions: Using target trial emulation, we found no significant effect of extended versus standard proning duration on mortality, ventilator liberation, or ICU discharge. However, given the imprecision of estimates, further study is justified.

Cost-Benefit Analysis of a Pediatric ICU Sedation Weaning Protocol.

A risk stratified sedation weaning protocol improved patient outcomes in a pediatric intensive care unit (PICU). We sought to determine the protocol effect on medication costs. This was a retrospective observational cohort study in an academic tertiary care children's hospital PICU (2018-2020) comparing the cost when weaning benzodiazepine, alpha agonist, and/or opioid infusions in intubated children <18 years of age. There were 84 total sedation weaning instances (pre-protocol n = 41 and post-protocol n = 41); 2 patients had 2 encounters, 1 in each phase. The total cost (in 2022 United States Dollars) of sedation weaning was $400,328.87 ($15,994.44/kg) pre-protocol compared with $170,458.85 ($11,227.52/kg) post-protocol. The median cost of sedation wean per patient for pre-protocol patients was $3197.42 (IQR: $322.66-$12,643.29) and post-protocol patients was $1851.44 (IQR: $425.05-$5355.85; p = 0.275). A linear regression model estimated the expected cost of sedation wean for post-protocol patients to be $5173.20 lower than for pre-protocol patients of the same weight and overall drug risk (p = 0.036). The proportion of withdrawal symptoms in the pre-protocol patients (16%) was not significantly different from the proportion in the post-protocol patients (14%; p = 0.435). Implementation of a PICU sedation weaning protocol in a single-center conferred cost benefit without negatively impacting patient outcomes. A larger multicenter study would provide insight to the applicability to PICUs in varied settings with differing patient populations.

The association between nutritional status measured by body mass index and outcomes in the pediatric intensive care unit.

The relationship between nutritional status upon admission to a pediatric intensive care unit (PICU) and clinical outcomes remains unclear. We examined the relationship between nutrition status, as indicated by body mass index-for-age (BMI-for-age), and clinical outcomes in the PICU. In this retrospective study at a tertiary care center, records of 1,015 critically ill children and adolescents aged one month to 18 years old with available anthropometric parameters were included. The nutritional status upon admission was determined by calculating the BMI-for-age z-score using the WHO growth charts as the reference. The participants were categorized as underweight (BMI-for-age z-score < -2), normal weight (-2 ≤ BMI-for-age z-score ≤ +1), and overweight/obese (BMI-for-age z-score > +1). Multi-variate odds ratios (OR) with 95% confidence intervals (CI) were used to investigate the association between malnutrition (being underweight and overweight/obese) and odds of Prolonged PICU stay (≥7 days) and PICU mortality after controlling for descriptive characteristics, Glasgow Coma Scale score status, fluctuations in serum sodium, and acute kidney injury confounders. The proportions of patients in underweight, normal weight, and overweight/obese categories were 34.2%, 45.8%, and 20%, respectively. During the study period, 21.5% of patients had prolonged PICU stay, and 5.6% of patients in PICU died. Compared to normal-weight patients, underweight patients had higher odds of prolonged PICU stay (OR: 1.52; 95% CI: 1.05-2.22) and PICU mortality (OR: 2.12; 95% CI: 1.22-4.01). Age- and gender-stratified full-adjusted analysis showed that the increased odds of prolonged PICU stay remained significant among underweight boys and underweight individuals aged 5-19 years old. Furthermore, the increased odds of PICU mortality remained significant among underweight individuals aged 2-5 years old. However, being overweight or obese during PICU admission did not demonstrate a significant association with our outcomes in the total sample or subgroup analysis. Our findings showed that PICU patients who were underweight had higher odds of prolonged PICU stay and PICU mortality than their normal-weight counterparts. This underscores the importance of closely monitoring underweight patients in the PICU upon admission in order to improve clinical outcomes.

Timing of Tracheostomy in ICU Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: The ideal timing for tracheostomy in critically ill patients is still debated. This systematic review and meta-analysis examined whether early tracheostomy improves clinical outcomes compared to late tracheostomy or prolonged intubation in critically ill patients on mechanical ventilation. Methods: We conducted a comprehensive search of randomized controlled trials (RCTs) assessing the risk of clinical outcomes in intensive care unit (ICU) patients who underwent early (within 7-10 days of intubation) versus late tracheostomy or prolonged intubation. Databases searched included PubMed, Embase, and the Cochrane Library up to June 2023. The primary outcome evaluated was mortality, while secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), ICU length of stay, and duration of mechanical ventilation. No language restriction was applied. Eligible studies were RCTs comparing early to late tracheostomy or prolonged intubation in critically ill patients that reported on mortality. The risk of bias was evaluated using the Cochrane Risk of Bias Tool for RCTs, and evidence certainty was assessed via the GRADE approach. Results: This systematic review and meta-analysis included 19 RCTs, covering 3586 critically ill patients. Early tracheostomy modestly decreased mortality compared to the control (RR -0.1511 [95% CI: -0.2951 to -0.0070], p = 0.0398). It also reduced ICU length of stay (SMD -0.6237 [95% CI: -0.9526 to -0.2948], p = 0.0002) and the duration of mechanical ventilation compared to late tracheostomy (SMD -0.3887 [95% CI: -0.7726 to -0.0048], p = 0.0472). However, early tracheostomy did not significantly reduce the duration of mechanical ventilation compared to prolonged intubation (SMD -0.1192 [95% CI: -0.2986 to 0.0601], p = 0.1927) or affect VAP incidence (RR -0.0986 [95% CI: -0.2272 to 0.0299], p = 0.1327). Trial sequential analysis (TSA) for each outcome indicated that additional trials are needed for conclusive evidence. Conclusions: Early tracheostomy appears to offer some benefits across all considered clinical outcomes when compared to late tracheostomy and prolonged intubation.

Impact of critical illness on continuation of anticancer treatment and prognosis of patients with aggressive hematological malignancies

BackgroundMaintaining the dose-intensity of cancer treatment is an important prognostic factor of aggressive hematological malignancies. The objective of this study was to assess the long-term outcomes of intensive care unit (ICU) survivors with acute myeloid leukemia (AML) or aggressive B-cell non-Hodgkin lymphoma (B-NHL) with emphasis on the resumption of the intended optimal regimen of cancer treatment.Patients and methodsWe conducted a retrospective (2013–2021) single-center observational study where we included patients with AML and B-NHL discharged alive from the ICU after an unplanned admission. The primary endpoint was the change in the intended optimal cancer treatment following ICU discharge. Secondary endpoints were 1-year progression-free survival and overall survival rates. Determinants associated with modifications in cancer treatment were assessed through multivariate logistic regression.ResultsOver the study period, 366 patients with AML or B-NHL were admitted to the ICU, of whom 170 survivors with AML (n = 92) and B-NHL (n = 78) formed the cohort of interest. The hematological malignancy was recently diagnosed in 68% of patients. The admission Sequential Organ Failure Assessment (SOFA) score was 5 (interquartile range 4–8). During the ICU stay, 30 patients (17.6%) required invasive mechanical ventilation, 29 (17.0%) vasopressor support, and 16 (9.4%) renal replacement therapy. The one-year survival rate following ICU discharge was 59.5%. Further modifications in hematologic treatment regimens were required in 72 patients (42%). In multivariate analysis, age > 65 years (odds ratio (OR) 3.54 [95%-confidence interval 1.67–7.50], p < 0.001), ICU-discharge hyperbilirubinemia > 20 µmol/L (OR 3.01 [1.10–8.15], p = 0.031), and therapeutic limitations (OR 16.5 [1.83–149.7], p = 0.012) were independently associated with modifications in cancer treatment. Post-ICU modifications of cancer treatment had significant impact on in-hospital, 1-year overall survival and progression-free survival.ConclusionThe intended cancer treatment could be resumed in 58% of ICU survivors with aggressive hematological malignancies. At the time of ICU discharge, advanced age, persistent liver dysfunction and decisions to limit further life-support therapies were independent determinants of cancer treatment modifications. These modifications were associated with worsened one-year outcomes.

A multi-state analysis on the effect of deprivation and race on PICU admission and mortality in children receiving Medicaid in United States (2007–2014)

IntroductionIn the United States (US), racial and socioeconomic disparities have been implicated in pediatric intensive care unit (PICU) admissions and outcomes, with higher rates of critical illness in more deprived areas. The degree to which this persists despite insurance coverage is unknown. We investigated whether disparities exist in PICU admission and mortality according to socioeconomic position and race in children receiving Medicaid.MethodsUsing Medicaid data from 2007–2014 from 23 US states, we tested the association between area level deprivation and race on PICU admission (among hospitalized children) and mortality (among PICU admissions). Race was categorized as Black, White, other and missing. Patient-level ZIP Code was used to generate a multicomponent variable describing area-level social vulnerability index (SVI). Race and SVI were simultaneously tested for associations with PICU admission and mortality.ResultsThe cohort contained 8,914,347 children (23·0% Black). There was no clear trend in odds of PICU admission by SVI; however, children residing in the most vulnerable quartile had increased PICU mortality (aOR 1·12 (95%CI 1·04–1·20; p = 0·0021). Black children had higher odds of PICU admission (aOR 1·04; 95% CI 1·03–1·05; p < 0·0001) and higher mortality (aOR 1·09; 95% CI 1·02–1·16; p = 0·0109) relative to White children. Substantial state-level variation was apparent, with the odds of mortality in Black children varying from 0·62 to 1·8.ConclusionIn a Medicaid cohort from 2007–2014, children with greater socioeconomic vulnerability had increased odds of PICU mortality. Black children were at increased risk of PICU admission and mortality, with substantial state-level variation. Our work highlights the persistence of sociodemographic disparities in outcomes even among insured children.

Explainable Artificial Intelligence for Early Prediction of Pressure Injury Risk.

Hospital-acquired pressure injuries (HAPIs) have a major impact on patient outcomes in intensive care units (ICUs). Effective prevention relies on early and accurate risk assessment. Traditional risk-assessment tools, such as the Braden Scale, often fail to capture ICU-specific factors, limiting their predictive accuracy. Although artificial intelligence models offer improved accuracy, their "black box" nature poses a barrier to clinical adoption. To develop an artificial intelligence-based HAPI risk-assessment model enhanced with an explainable artificial intelligence dashboard to improve interpretability at both the global and individual patient levels. An explainable artificial intelligence approach was used to analyze ICU patient data from the Medical Information Mart for Intensive Care. Predictor variables were restricted to the first 48 hours after ICU admission. Various machine-learning algorithms were evaluated, culminating in an ensemble "super learner" model. The model's performance was quantified using the area under the receiver operating characteristic curve through 5-fold cross-validation. An explainer dashboard was developed (using synthetic data for patient privacy), featuring interactive visualizations for in-depth model interpretation at the global and local levels. The final sample comprised 28 395 patients with a 4.9% incidence of HAPIs. The ensemble super learner model performed well (area under curve = 0.80). The explainer dashboard provided global and patient-level interactive visualizations of model predictions, showing each variable's influence on the risk-assessment outcome. The model and its dashboard provide clinicians with a transparent, interpretable artificial intelligence-based risk-assessment system for HAPIs that may enable more effective and timely preventive interventions.

Effects of dexmedetomidine versus propofol on outcomes in critically ill patients with different sedation depths: a propensity score-weighted cohort study

ObjectiveWe explored the effects of dexmedetomidine (DEX) versus propofol on outcomes in critically ill patients and to assess whether these effects are dissimilar under different sedation depths. MethodsA stabilized inverse probability of treatment weighting cohort study was conducted using data from the Medical Information Mart for Intensive Care IV database from 2008 to 2019. Adult intensive care unit (ICU) patients who were administered DEX or propofol as the primary sedative were identified. Various statistical methods were used to evaluate the effects of DEX versus propofol on outcomes. ResultsData on 107 and 2318 patients in DEX and propofol groups, respectively, were analyzed. Compared to the propofol group, the DEX group exhibited longer ventilator-free days on day 28 and a shorter ICU stay. Conversely, it showed null associations of DEX with the risk of 90-day ICU mortality, the odds of persistent organ dysfunction on day 14 and acute kidney injury, and the duration of vasopressor-free days on day 28. Subgroup analyses revealed that DEX positively impacted persistent organ dysfunction on day 14, ventilator-free days on day 28, and ICU stay in the subgroup with a Richmond Agitation Sedation Scale (RASS) score of ≥−2. However, DEX negatively impacted 90-day ICU mortality, persistent organ dysfunction on day 14, and ventilator-free days on day 28 in the subgroup with a RASS score of <−2. ConclusionOur results indicated that, compared with propofol, DEX had beneficial and adverse impacts on certain ICU outcomes in critically ill patients, and these impacts appeared to depend on sedation depths.

Analysis of metabolic alterations as 30 days intensive care mortality predictors for patients undergoing continuous renal replacement therapy

BackgroundAcute kidney injury patients on continuous renal replacement therapy are subjected to alterations in metabolism, which in turn are associated with worse clinical outcome and mortality. The aim of this study is to determine which metabolism indicators can be used as independent predictors of 30 days intensive care unit (ICU) mortality. MethodsThis was a prospective observational study on critical care patients on renal replacement therapy. Integrated approach of metabolism evaluation was used, combining the energy expenditure measured by indirect calorimetry, bioelectrical impedance provided fat free mass index (FFMI), amino acid and glucose concentrations. ICU mortality was defined as all cause 30 days mortality. Regression analysis was conducted to determine the conventional and metabolism associated predictors of mortality. ResultsThe study was conducted between the 2021 March and 2022 October. 60 high mortality risk patients (APACHE II of 22.98±7.87, 97% on vasopressors, 100% on mechanical ventilation) were included during the period of the study. The rate of 30 days ICU mortality was 50% (n=30). Differences across survivors and non-survivors in metabolic predictors were noted in energy expenditure (kcal/kg/day) (19.79 ±5.55 vs 10.04 ±3.97 p=0.013), amino acid concentrations (mmol/L) (2.40 ±1.06 vs 1.87 ±0.90 p=0.040) and glucose concentrations (mmol/L) (7.89 ±1.90 vs 10.04 ±3.97 p=0.010). No differences were noted in FFMI (23.38 ±4.25 vs 21.95 ±3.08 p=0.158). In the final linear regression analysis model, lower energy expenditure (exp(B)= 0.852 CI95%: 0.741-0.979 p=0.024) and higher glucose (exp(B)=1.360 CI95%: 1.013-1.824 p=0.041) remained as independent predictors of the higher mortality. ConclusionThe results of the study imply strong association between the metabolic alterations and ICU outcome. Our findings suggest that lower systemic amino acid concentration, lower energy expenditure and higher systemic glucose concentration are predictive of 30 days ICU mortality.

Neuromonitoring practices for neonates with congenital heart disease: a scoping review.

Neonates with congenital heart disease (CHD) are at risk for adverse neurodevelopmental outcomes. This scoping review summarizes neuromonitoring methods in neonates with CHD. We identified 84 studies investigating the use of near-infrared spectroscopy (NIRS) (n = 37), electroencephalography (EEG) (n = 20), amplitude-integrated electroencephalography (aEEG) (n = 10), transcranial Doppler sonography (TCD) (n = 6), and multimodal monitoring (n = 11). NIRS was used to evaluate cerebral oxygenation, identify risk thresholds and adverse events in the intensive care unit (ICU), and outcomes. EEG was utilized to screen for seizures and to predict adverse outcomes. Studies of aEEG have focused on characterizing background patterns, detecting seizures, and outcomes. Studies of TCD have focused on correlation with short-term clinical outcomes. Multimodal monitoring studies characterized cerebral physiologic dynamics. Most of the studies were performed in single centers, had a limited number of neonates (range 3-183), demonstrated variability in neuromonitoring practices, and lacked standardized approaches to neurodevelopmental testing. We identified areas of improvement for future research: (1) large multicenter studies to evaluate developmental correlates of neuromonitoring practices; (2) guidelines to standardize neurodevelopmental testing methodologies; (3) research to address geographic variation in resource utilization; (4) integration and synchronization of multimodal monitoring; and (5) research to establish a standardized framework for neuromonitoring techniques across diverse settings. IMPACT: This scoping review summarizes the literature regarding neuromonitoring practices in neonates with congenital heart disease (CHD). The identification of low cerebral oxygenation thresholds with NIRS may be used to identify neonates at risk for adverse events in the ICU or adverse neurodevelopmental outcomes. Postoperative neuromonitoring with continuous EEG screening for subclinical seizures and status epilepticus, allow for early and appropriate therapy. Future studies should focus on enrolling larger multicenter cohorts of neonates with CHD with a standardized framework of neuromonitoring practices in this population. Postoperative neurodevelopmental testing should utilize standard assessments and testing intervals.

Contribution of ethnicity, area level deprivation and air pollution to paediatric intensive care unit admissions in the United Kingdom 2008–2021

There is emerging evidence on the impact of social and environmental determinants of health on paediatric intensive care unit (PICU) admissions and outcomes. We analysed UK paediatric intensive care data to explore disparities in the incidence of admission according to a child's ethnicity and the degree of deprivation and pollution in the child's residential area. Data were extracted on children <16 years admitted to UK PICUs between 1st January 2008 and 31st December 2021 from the Paediatric Intensive Care Audit Network (PICANet) database. Ethnicity was categorised as White, Asian, Black, Mixed or Other. Deprivation was quantified using the 'children in low-income families' measure and outdoor air pollution was characterised using mean annual PM2.5 level at local authority level, both divided into population-weighted quintiles. UK population estimates were used to calculate crude incidence of PICU admission. Incidence rate ratios were calculated using Poisson regression models. There were 245,099 admissions, of which 60.7% were unplanned. After adjusting for age and sex, Asian and Black children had higher relative incidence of unplanned PICU admission compared to White (IRR 1.29 [95% CI: 1.25-1.33] and 1.50 [95% CI: 1.44-1.56] respectively), but there was no evidence of increased incidence of planned admission. Children living in the most deprived quintile had 1.50 times the incidence of admission in the least deprived quintile (95% CI: 1.46-1.54). There were higher crude admission levels of children living in the most polluted quintile compared to the least (157.8 vs 113.6 admissions per 100,000 child years), but after adjustment for ethnicity, deprivation, age and sex there was no association between pollution and PICU admission (IRR 1.00 [95% CI: 1.00-1.00] per 1μg/m3 increase). Ethnicity and deprivation impact the incidence of PICU admission. When restricting to unplanned respiratory admissions and ventilated patients only, increasing pollution level was associated with increased incidence of PICU admission. It is essential to act to reduce these observed disparities, further work is needed to understand mechanisms behind these findings and how they relate to outcomes. There was no direct funding for this project. HM was funded by an NIHR Academic Clinical Fellowship (ACF-2022-18-017).