Outcome In ICU Patients Research Articles

High-dose methotrexate in ICU patients: a retrospective study

BackgroundHigh-dose methotrexate (HD-MTX) is commonly used in the treatment of solid tumors and hematological malignancies. Severe toxicities are frequent, leading to organ dysfunction and death. Risk–benefit ratio of using HD-MTX in critically ill patients is unknown. This study aims to describe MTX-induced toxicities and to assess outcome in ICU patients. We conducted a retrospective single-center study conducted in a university hospital ICU between January 2002 and December 2018. Consecutive patients treated by HD-MTX were included.Results33 patients (24 men and 9 women) aged 48 years [34–63], were included. B cell lymphoma had been diagnosed in 31 patients (Burkitt, n = 14; diffuse large B-cell lymphoma with CNS (central nervous system) involvement, n = 9; primary CNS lymphoma, n = 5) and T-cell lymphoma in two patients. Patients were mainly admitted for coma (n = 14; 42%) or acute kidney injury (n = 8; 24%). MTX was administered at a median dose of 6.1 g [5–14]. Fourteen patients had concomitant medication interacting with MTX. Median MTX clearance was 4 days [4–5]. Frequent MTX-related complication were mucositis (n = 21, 64%), diarrhea (n = 14, 44%) or hepatic failure (n = 15, 45%). During ICU stay, 11 patients experienced acute kidney injury (KDIGO stage 3 [2–3]). Two patients received carboxypeptidase and three underwent dialysis. Overall, 19 patients (57%) required mechanical ventilation, 10 (30%) vasopressors. Hospital mortality was 30% (n = 10). Cox model identified MTX concentration 24 h after administration higher than 4.6 µmol/L as associated with hospital mortality (HR 6.7; 95% CI 1.6–27.3).ConclusionsTo our knowledge, this is the first study assessing characteristics and outcome of critically ill patients receiving HD-MTX. MTX concentration at H24 was associated with hospital mortality. Despite underlying malignancy, ICU support of these patients was associated with a meaningful survival.

Delirium Severity Trajectories and Outcomes in ICU Patients. Defining a Dynamic Symptom Phenotype.

Rationale: Delirium severity and duration are independently associated with higher mortality and morbidity. No studies to date have described a delirium trajectory by integrating both severity and duration.Objectives: The primary aim was to develop delirium trajectories by integrating symptom severity and duration. The secondary aim was to investigate the association among trajectory membership, clinical characteristics, and 30-day mortality.Methods: A secondary analysis of the PMD (Pharmacologic Management of Delirium) randomized control trial (ClinicalTrials.gov Identifier: NCT00842608; N = 531) was conducted. The presence of delirium and symptom severity were measured at least daily for 7 days using the Confusion Assessment Method for the intensive care unit (CAM-ICU) and CAM-ICU-7 (on a scale of 0-7, with 7 being the most severe). Delirium trajectories were defined using an innovative, data-driven statistical method (group-based trajectory modeling [GBTM]) and SAS v9.4.Results: A total of 531 delirious participants (mean age 60 yr [standard deviation = 16], 55% female, and 46% African American) were analyzed. Five distinct delirium trajectories were described (CAM-ICU-7: mean [standard deviation]); mild-brief (CAM-ICU-7: 0.5 [0.5]), severe-rapid recovers (CAM-ICU-7: 2.1 [1.0]), mild-accelerating (CAM-ICU-7: 2.2 [0.9]), severe-slow recovers (CAM-ICU-7: 3.9 [0.9]), and severe-nonrecovers (CAM-ICU-7: 5.9 [1.0]). Baseline cognition and race were associated with trajectory membership. Trajectory membership independently predicted 30-day mortality while controlling for age, sex, race, cognition, illness severity, and comorbidities.Conclusions: This secondary analysis described five distinct delirium trajectories based on delirium symptom severity and duration using group-based trajectory modeling. Trajectory membership predicted 30-day mortality.

Exploration of critical care data by using unsupervised machine learning

Background and ObjectiveIdentification of subgroups may be useful to understand the clinical characteristics of ICU patients. The purposes of this study were to apply an unsupervised machine learning method to ICU patient data to discover subgroups among them; and to examine their clinical characteristics, therapeutic procedures conducted during the ICU stay, and discharge dispositions. MethodsK-means clustering method was used with 1503 observations and 9 types of laboratory test results as features. ResultsThree clusters were identified from this specific population. Blood urea nitrogen, creatinine, potassium, hemoglobin, and red blood cell were distinctive between the clusters. Cluster Three presented the highest blood products transfusion rate (19.8%), followed by Cluster One (15.5%) and cluster Two (9.3%), which was significantly different. Hemodialysis was more frequently provided to Cluster Three while bronchoscopy was done to Cluster One and Two. Cluster Three showed the highest mortality (30.4%), which was more than two-fold compared to Cluster One (14.1%) and Two (12.2%). ConclusionThree subgroups were identified and their clinical characteristics were compared. These findings may be useful to anticipate treatment strategies and probable outcomes of ICU patients. Unsupervised machine learning may enable ICU multi-dimensional data to be organized and to make sense of the data.

Association Between Consecutive Days Worked by Intensivists and Outcomes for Critically Ill Patients.

To evaluate the association between consecutive days worked by intensivists and ICU patient outcomes. Retrospective cohort study linked with survey data. Australia and New Zealand ICUs. Adults (16+ yr old) admitted to ICU in the Australia New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Registries (July 1, 2016, to June 30, 2018). None. We linked data on staffing schedules for each unit from the Critical Care Resources Registry 2016-2017 annual survey with patient-level data from the Adult Patient Database. The a priori chosen primary outcome was ICU length of stay. Secondary outcomes included hospital length of stay, ICU readmissions, and mortality (ICU and hospital). We used multilevel multivariable regression modeling to assess the association between days of consecutive intensivist service and patient outcomes; the predicted probability of death was included as a covariate and individual ICU as a random effect. The cohort included 225,034 patients in 109 ICUs. Intensivists were scheduled for seven or more consecutive days in 43 (39.4%) ICUs; 27 (24.7%) scheduled intensivists for 5 days, 22 (20.1%) for 4 days, seven (6.4%) for 3 days, four (3.7%) for 2 days, and six (5.5%) for less than or equal to 1 day. Compared with care by intensivists working 7+ consecutive days (adjusted ICU length of stay = 2.85 d), care by an intensivist working 3 or fewer consecutive days was associated with shorter ICU length of stay (3 consecutive days: 0.46 d fewer, p = 0.010; 2 consecutive days: 0.77 d fewer, p < 0.001; ≤ 1 consecutive days: 0.68 d fewer, p < 0.001). Shorter schedules of consecutive intensivist days worked were also associated with trends toward shorter hospital length of stay without increases in ICU readmissions or hospital mortality. Care by intensivists working fewer consecutive days is associated with reduced ICU length of stay without negatively impacting mortality.

Impact of having a certified nurse specialist in critical care nursing as head nurse on ICU patient outcomes.

ObjectivesThis study evaluated the impact of the presence of a certified nurse specialist in critical care (CNS) as ICU head nurse in an open ICU on clinical outcomes.MethodsThe presence of a CNS as ICU head nurse was implemented in practice in April 2017. To evaluate the impact on patient outcomes before and after the implementation, patients were divided into two groups: before (April 2014 to March 2017; 1988 patients) and after (April 2017 to March 2019; 1664 patients). Patients’ demographic data were collected from the ICU database.ResultsMultivariable logistic regression analysis revealed that the presence of a CNS as ICU head nurse was associated with lower ICU mortality (odds ratio (OR): 0.52, 95% CI: 0.36–0.73, p < .001) and fewer patients receiving mechanical ventilation in the ICU (OR: 0.20, 95% CI: 0.15–0.26, p < .001).ConclusionCNSs are defined as one type of advanced practice nurses. Having a CNS as a head nurse in the ICU may have helped improve patient outcomes by leveraging these practical skills in nursing management.

Effectiveness Of&amp;nbsp;Bundle&amp;nbsp;Interventions on ICU Delirium: A Meta-Analysis

Background: Bundle interventions are often used to prevent and manage ICU delirium, but different outcomes were found across studies. We aimed to evaluate the impact of bundle interventions on ICU delirium incidence and other clinical outcomes. Methods: We conducted a meta-analysis of randomized clinical trials, controlled trials or before-after studies that related to bundle interventions from January 2000 to October 2019. The primary outcome was ICU delirium incidence. Data were pooled by random- or fixed-effects models. Effect size measures were mean difference (MD), or risk ratio (RR) with 95% confidence intervals (CI). Findings: Twenty-five studies with a total of 25,328 adult participants were included in the meta-analysis. The incidence of ICU delirium was reduced by 22% (RR=0·78; 95%CI, 0·70-0·88) in intervention group. Meta-analysis showed that bundle interventions was associated with shortening the duration of ICU delirium (MD=-1·83days; 95% CI, -2·39 to -1·27), increasing ventilator-free days (MD=2·53days; 95%CI, 1·31-3·75), shortening ICU length of stay (MD=-1·04days; 95%CI, -1·59 to -0·50), decreasing in-hospital mortality by 17% (RR=0·83; 95%CI, 0·69 to 0·99) and 28-day mortality by 22% (RR=0·78; 95%CI, 0·63-0·96). Interpretation: Bundle interventions are effective in reducing the incidence and duration of ICU delirium. The meta-analysis supports the recommendation that bundle interventions have shown improved outcomes in ICU patients. Funding Statement: This study was supported by Grant 71661167008 from the National Natural Science Foundation of China. Declaration of Interests: The authors declare that they have no conflicts of interest.

Early Palliative Care Consultation in the Medical ICU: A Cluster Randomized Crossover Trial.

To assess the impact of early triggered palliative care consultation on the outcomes of high-risk ICU patients. Single-center cluster randomized crossover trial. Two medical ICUs at Barnes Jewish Hospital. Patients (n = 199) admitted to the medical ICUs from August 2017 to May 2018 with a positive palliative care screen indicating high risk for morbidity or mortality. The medical ICUs were randomized to intervention or usual care followed by washout and crossover, with independent assignment of patients to each ICU at admission. Intervention arm patients received a palliative care consultation from an interprofessional team led by board-certified palliative care providers within 48 hours of ICU admission. Ninety-seven patients (48.7%) were assigned to the intervention and 102 (51.3%) to usual care. Transition to do-not-resuscitate/do-not-intubate occurred earlier and significantly more often in the intervention group than the control group (50.5% vs 23.4%; p < 0.0001). The intervention group had significantly more transfers to hospice care (18.6% vs 4.9%; p < 0.01) with fewer ventilator days (median 4 vs 6 d; p < 0.05), tracheostomies performed (1% vs 7.8%; p < 0.05), and postdischarge emergency department visits and/or readmissions (17.3% vs 38.9%; p < 0.01). Although total operating cost was not significantly different, medical ICU (p < 0.01) and pharmacy (p < 0.05) operating costs were significantly lower in the intervention group. There was no significant difference in ICU length of stay (median 5 vs 5.5 d), hospital length of stay (median 10 vs 11 d), in-hospital mortality (22.6% vs 29.4%), or 30-day mortality between groups (35.1% vs 36.3%) (p > 0.05). Early triggered palliative care consultation was associated with greater transition to do-not-resuscitate/do-not-intubate and to hospice care, as well as decreased ICU and post-ICU healthcare resource utilization. Our study suggests that routine palliative care consultation may positively impact the care of high risk, critically ill patients.

Prospective Study of clinical profile and outcome in Surgical ICU patients

Prospective Study of clinical profile and outcome in Surgical ICU patients

Inter-Rater Reliability and Impact of Disagreements on Acute Physiology and Chronic Health Evaluation IV Mortality Predictions.

Objectives:Acute Physiology and Chronic Health Evaluation is a well-validated method to risk-adjust ICU patient outcomes. However, predictions may be affected by inter-rater reliability for manually entered elements. We evaluated inter-rater reliability for Acute Physiology and Chronic Health Evaluation IV manually entered elements among clinician abstractors and assessed the impacts of disagreements on mortality predictions.Design:Cross-sectional.Setting:Academic medical center.Subjects:Patients admitted to five adult ICUs.Interventions:None.Measurements and Main Results:Acute Physiology and Chronic Health Evaluation IV manually entered elements were abstracted from a selection of charts (n = 41) by two clinician “raters” trained in Acute Physiology and Chronic Health Evaluation IV methodology. Rater agreement (%) was determined for each manually entered element, including Acute Physiology and Chronic Health Evaluation diagnosis, Glasgow Coma Scale score, admission source, chronic conditions, elective/emergency surgery, and ventilator use. Cohen’s kappa (K) or intraclass correlation coefficient was calculated for nominal and continuous manually entered elements, respectively. The impacts of manually entered element choices on Acute Physiology and Chronic Health Evaluation IV mortality predictions were computed using published Acute Physiology and Chronic Health Evaluation IV equations, and observed to expected hospital mortality ratios were compared between rater groups. The majority of manually entered element inconsistency was due to disagreement in choice of Glasgow Coma Scale (63.8% agreement, 0.83 intraclass correlation coefficient), Acute Physiology and Chronic Health Evaluation diagnosis (68.3% agreement, 0.67 kappa), and admission source (90.2% agreement, 0.85 kappa). The difference in predicted mortality between raters related to Glasgow Coma Scale disagreements was significant (observed to expected mortality ratios for Rater 1 [1.009] vs Rater 2 [1.134]; p < 0.05). Differences related to Acute Physiology and Chronic Health Evaluation diagnosis or admission source disagreements were negligible. The new “unable to score” choice for Glasgow Coma Scale was used for 18% of Glasgow Coma Scale measurements but accounted for 63% of “major” Glasgow Coma Scale disagreements, and 50% of the overall difference in Acute Physiology and Chronic Health Evaluation-predicted mortality between raters.Conclusions:Inconsistent use among raters of the new “unable to score” choice for Glasgow Coma Scale introduced in Acute Physiology and Chronic Health Evaluation IV was responsible for important decreases in both Glasgow Coma Scale and Acute Physiology and Chronic Health Evaluation IV mortality prediction reliability in our study. A Glasgow Coma Scale algorithm we developed after the study to improve reliability related to use of this new “unable to score” choice is presented.

The glutamine debate in surgery and critical care.

Glutamine (GLN) is a versatile amino acid, long believed to have important implications in ICU and surgical patients. An extensive body of data examining GLN supplementation of TPN demonstrated a consistent signal of improved outcomes. However, recently signals of risk have come from two large-scale multicenter trials evaluating GLN (and other nutrients) at high dose and as primary pharmaconutrients, not as supplementation to complete nutrition. These trials indicate a risk of increased mortality when GLN is given to patients in shock, renal failure, and early in acute phase of critical care. Recent literature continues to confirm that low and high admission GLN levels are associated with increased ICU mortality and adverse outcomes. Further, a recent meta-analysis examined trials utilizing GLN-supplemented TPN in stabile ICU patients consistent with current clinical guidelines. This analysis showed GLN supplementation of TPN led to reduced infections, LOS and hospital mortality. Three recent meta-analyses have confirmed traditional GLN-supplemented (or 'GLN-Complemented' - providing GLN for completeness of amino acid content) TPN is safe, reduces mortality and improves outcome in surgical and ICU patients. Patients in need of TPN, burns, trauma or malignancies should continue to benefit from supplemental GLN, administered either intravenously at less than 0.35 g/kg/day or enterally at less than 0.5 g/kg/day. Further, a large trial of EN GLN supplementation in burns is ongoing. Thus, when used per guideline recommendations, the GLN story is likely still relevant to ICU outcomes and research.

Characteristics and outcome of high-cost ICU patients.

PurposeCare at ICUs is expensive and variable depending on the type of care that the patients received. Knowing the characteristics of the patient and his or her disease is always useful for improving health services and cost containment.Patients and methodsAn observational study was conducted at four different intensive care units of an academic medical institution. Demographic characteristics, disease-management casemix information, cost and outcome of the high costing decile, and the rest of the cases were compared.ResultsA total of 3,220 discharges were included in the study. The high-cost group contributed 35.4% of the ICU stays and 38.8% of the total ICU expenditure. Diseases of the central nervous system had higher odds to be in the top decile of costly patients whereas the cardiovascular system was more likely to be in the non-high cost category. The high-cost patients were more likely to have death as an outcome (19.2% vs 9.3%; p<0.001). The most common conditions that were in the high-cost groups were craniotomy, other ear, nose, mouth, and throat operations, simple respiratory system operations, complex intestinal operations, and septicemia. These five diagnostic groups made up 43% of the high-cost decile.ConclusionHigh-cost patients utilized almost 40% of the ICU cost although they were only 10% of the ICU patients. The chances of admission to the ICU increased with older age and severity level of the disease. Central nervous system diseases were the major problem of patients aged 46–69 years old. In addition to cost reduction strategies at the treatment level, detailed analysis of these cases was needed to explore and identify pre-event stage prevention strategies.

Risk Factors of Delirium in ICU Patients with Acute Poisoning

Purpose: This study estimated the incidence of delirium and associated risk factors and outcomes in ICU patients with acute poisoning. Methods: Data were collected from ICU patients over 18 years of age that were admitted via the emergency center after presenting with poisoning from 2010 to 2015. Delirium was assessed retrospectively using the Intensive Care Delirium Screening Checklist (ICDSC). Risk factors were evaluated by univariate and multivariate analysis. Results: A total of 199 patients participated in this study and 68 (34.2%) were diagnosed with delirium based on the ICDSC score. The delirium group showed a significantly higher association with prolonged length of stay in the hospital and ICU in comparison with the non-delirium group. The delirium group was associated with greater use of physical restraint. A statistically greater number of patients with pharmaceutical substance poisoning developed delirium over a short period of time than those with non-pharmaceutical substance poisoning. There was no significant difference between the two groups with respect to age, sex, past history, GCS score, vital signs, application of ventilator care and renal replacement therapy. Conclusion: The finding that the delirium group had a greater length of stay in both the hospital and the ICU is consistent with the results of previous worldwide studies of the effects of delirium on the prognosis of patients who were admitted to the ICU, suggesting the possibility for domestic application. Additionally, use of physical restraint was positively related to the incidence of delirium. Thus, interventions for minimizing the use of physical restraints and considering alternatives are needed.

1300-P: Hyperglycemia Is Associated with Worse Outcomes in Neurosurgery Only in Patients without Diabetes

Hyperglycemia is associated with adverse outcomes in critically ill surgical patients with increasing recognition that those without preexisting DM (NODM) are more affected. As the brain acts as a major regulator of glucose and exclusively depends on it for its high energy needs, we examined the association between hyperglycemia and outcomes in ICU patients undergoing elective or emergent neurosurgery (NSGY) with and without DM. Patients (N 864) were grouped as NODM, pre-existing DM on (DMTR) and not on medications (DMNT) (NODM 637 DMNT 80 DMTR 147). Postop glucose (BG) and time weighted average BG (TWAg) 24 hours postop, postop length of stay (pLOS), hospitalization cost and adverse outcomes (death, respiratory failure, infection, stroke, MI) were obtained retrospectively from admissions between May 2011 - January 2015. Those in DMTR had higher TWAg than in DMNT and NODM (188 vs. 166, 145 mg/dL p&amp;lt;0.005). After adjustment for demographics, comorbidities and surgical characteristics, NODM patients with hyperglycemia (mean of 2 consecutive BG &amp;gt; 180 mg/dL) had higher costs and pLOS while those in DMTR had lower cost and shorter pLOS. Those in NODM with hyperglycemia had more adverse events than those without; this was not seen in DMNT and DMTR (Figure). We found in NSGY patients, hyperglycemia’s association with adverse events depends on DM status and stresses the need to understand underlying mechanisms. Disclosure G. Greco: None. A.J. Moskowitz: None. D.W. Lam: Research Support; Self; Novo Nordisk A/S.

Telemedicine in the ICU: clinical outcomes, economic aspects, and trainee education.

The evidence base for telemedicine in the ICU (tele-ICU) is rapidly expanding. The last 2 years have seen important additions to our understanding of when, where, and how telemedicine in the ICU adds value. Recent publications and a recent meta-analysis confirm that tele-ICU improves core clinical outcomes for ICU patients. Recent evidence further demonstrates that comprehensive tele-ICU programs have the potential to quickly recuperate their implementation and operational costs and significantly increase case volumes and direct contribution margins particularly if additional logistics and care standardization functions are embedded to optimize ICU bed utilization and reduce complications. Even though the adoption of tele-ICU is increasing and the vast majority of today's medical graduates will regularly use some form of telemedicine and/or tele-ICU, telemedicine modules have not consistently found their way into educational curricula yet. Tele-ICU can be used very effectively to standardize supervision of medical trainees in bedside procedures or point-of-care ultrasound exams, especially during off-hours. Lastly, tele-ICUs routinely generate rich operational data, as well as risk-adjusted acuity and outcome data across the spectrum of critically ill patients, which can be utilized to support important clinical research and quality improvement projects. The value of tele-ICU to improve patient outcomes, optimize ICU bed utilization, increase financial performance and enhance educational opportunities for the next generation of providers has become more evident and differentiated in the last 2 years.

Fever control in critically ill adults. An individual patient data meta-analysis of randomised controlled trials.

One potential way to protect patients from the physiological demands that are a consequence of fever is to aim to prevent fever and to treat it assiduously when it occurs. Our primary hypothesis was that more active fever management would increase survival among patient subgroups with limited physiological reserves such as older patients, patients with higher illness acuity, and those requiring organ support. We conducted an individual-level patient data meta-analysis of randomised controlled trials to compare the outcomes of ICU patients who received more active fever management with the outcomes of patients who received less active fever management. The primary outcome variable of interest was the unadjusted time to death after randomisation. Of 1413 trial participants, 707 were assigned to more active fever management and 706 were assigned to less active fever management. There was no statistically significant heterogeneity in the effect of more active compared with less active fever management on survival in any of the pre-specified subgroups that were chosen to identify patients with limited physiological reserves. Overall, more active fever management did not result in a statistically significant difference in survival time compared with less active fever management [hazard ratio 0.91; (95% CI 0.75-1.10), P = 0.32]. Our findings do not support the hypothesis that more active fever management increases survival compared with less active fever management overall or in patients with limited physiological reserves.

Critical Care Short Term Outcomes of Cancer Patients in Australasia

Introduction: Cancer treatment has leaped forwards in the last 20 years, with a 20% decrease in overall ICU mortality whilst making around 15% of ICU admissions. The outcomes of ICU patients with a cancer diagnosis has not been extensively studied in Australasia.

A study to evaluate effect of PEEP and end-tidal carbon dioxide on optic nerve sheath diameter.

Background and Aims:PEEP is commonly used to improve postoperative respiratory outcomes in surgical and ICU patients. It is thought to increase ICP by impending CSF outflow and cerebral venous drainage. Hyperventilation is used to decrease ICP in patients having intracranial hypertension. We investigated the effect of various levels of PEEP and EtCO2 on ONSD as an indirect predictor of ICP in patients undergoing surgery under GA.Methods:After induction, different levels of PEEP and EtCO2 were applied to 50 patients. Sonographic ONSD was measured 5 minutes after stabilization of each new setting. Haemodynamic parameters like pulse, SpO2, BP were also recorded. Quantitative variables were expressed as Mean ± SD and compared across between follow-ups using paired t-test. Qualitative variables were expressed in number and percentage.Results:Baseline ONSD was 0.44 ± 0.06 cm. It increased significantly to 0.45 ± 0.07 cm, 0.47 ± 0.07 cm and 0.49 ± 0.07 cm after applying PEEP of 8, 12 and 15 cm H2O PEEP, respectively. It significantly decreased to 0.42 ± 0.06 cm, 0.41 ± 0.06 cm and 0.40 ± 0.06 cm after hyperventilation, EtCO2 range 35–37, 32–34 and 29–31 mm Hg. Results were statistically significant but clinically not significant.Conclusion:We conclude that there are acute and dynamic alterations in ONSD in response to hyperventilation and presence of PEEP in anaesthetised patients. Ocular sonography may be used as a reliable indicator of acute variations in ICP.

Impact of Multiprofessional Rounds on Critical Care Outcomes in the Surgical Trauma Intensive Care Unit

Multiprofessional rounds (MPR) represent a mechanism for the coordination of care in critically ill patients. Herein, we examined the impact of MPR on ventilator days (Vent-day), ICU length of stay (LOS), hospital LOS (HLOS), and mortality. A team developed guidelines for MPR, which began in February 2016. Patients admitted between November 2015 and March 2017 with Acute Physiology and Chronic Health Evaluation (APACHE) IV and injury severity scores were included. Outcome data consisted of Vent-day, Vent-day observed/expected ratio (O/E), ICU LOS, ICU LOS O/E, HLOS, HLOS-O/E, and mortality. Linear regression models are constructed to assess statistical significance. A total of 3372 patients were included. Among surgical patients (n = 343 pre-MPR, n = 1675 post-MPR), MPR was associated with decreases in Vent-day O/E (0.74 pre, 0.59 post, P = 0.03), ICU LOS O/E (0.67 pre, 0.61 post, P = 0.01), and HLOS-O/E (1.47 pre, 1.22 post, P = 0.0005). No mortality difference was observed. For trauma patients (n = 221 pre, n = 1133 post), MPR resulted in a reduction in Vent-days (2.2 days pre, 1.6 days post, P = 0.05). However, no differences were observed for Vent-day O/E, ICU LOS O/E, HLOS-O/E, and mortality. Implementation of MPR was associated with improved outcomes for surgical trauma ICU patients. Sustainability of MPR remains a challenge and requires education and engagement.

ECG derived Cheyne–Stokes respiration and periodic breathing are associated with cardiorespiratory arrest in intensive care unit patients

BackgroundCheyne-Stokes respiration and periodic breathing (CSRPB) have not been studied sufficiently in the intensive care unit setting (ICU). ObjectivesTo determine whether CSRPB is associated with adverse outcomes in ICU patients. MethodsThe ICU group was divided into quartiles by CSRPB (86 patients in quartile 1 had the least CSRPB and 85 patients in quartile 4 had the most CSRPB). Adverse outcomes (emergent intubation, cardiorespiratory arrest, inpatient mortality and the composite of all) were compared between patients with most CSRPB (quartile 4) and those with least CSRPB (quartile 1). ResultsICU patients in quartile 4 had a higher proportion of cardiorespiratory arrests (5% versus 0%, (p=.042), and more adverse events over all (19% versus 8%, p=.041) as compared to patients in quartile 1. ConclusionsCSRPB can be measured in the ICU and it's severity is associated with adverse outcomes in critically ill patients.

Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts.

Mechanical power (MP) may unify variables known to be related to development of ventilator-induced lung injury. The aim of this study is to examine the association between MP and mortality in critically ill patients receiving invasive ventilation for at least 48h. This is an analysis of data stored in the databases of the MIMIC-III and eICU. Critically ill patients receiving invasive ventilation for at least 48h were included. The exposure of interest was MP. The primary outcome was in-hospital mortality. Data from 8207 patients were analyzed. Median MP during the second 24h was 21.4 (16.2-28.1) J/min in MIMIC-III and 16.0 (11.7-22.1) J/min in eICU. MP was independently associated with in-hospital mortality [odds ratio per 5J/min increase (OR) 1.06 (95% confidence interval (CI) 1.01-1.11); p = 0.021 in MIMIC-III, and 1.10 (1.02-1.18); p = 0.010 in eICU]. MP was also associated with ICU mortality, 30-day mortality, and with ventilator-free days, ICU and hospital length of stay. Even at low tidal volume, high MP was associated with in-hospital mortality [OR 1.70 (1.32-2.18); p < 0.001] and other secondary outcomes. Finally, there is a consistent increase in the risk of death with MP higher than 17.0J/min. High MP of ventilation is independently associated with higher in-hospital mortality and several other outcomes in ICU patients receiving invasive ventilation for at least 48h.