Post Intensive Care Unit Admission Research Articles

Attributable mortality of acute kidney injury among critically ill patients with sepsis: a multicenter, retrospective cohort study

BackgroundSepsis and acute kidney injury (AKI) are common severe diseases in the intensive care unit (ICU). This study aimed to estimate the attributable mortality of AKI among critically ill patients with sepsis and to assess whether AKI was an independent risk factor for 30-day mortality.MethodsThe information we used was derived from a multicenter prospective cohort study conducted in 18 Chinese ICUs, focusing on septic patients post ICU admission. The patients were categorized into two groups: those who developed AKI (AKI group) within seven days following a sepsis diagnosis and those who did not develop AKI (non-AKI group). Using propensity score matching (PSM), patients were matched 1:1 as AKI and non-AKI groups. We then calculated the mortality rate attributable to AKI in septic patients. Furthermore, a survival analysis was conducted comparing the matched AKI and non-AKI septic patients. The primary outcome of interest was the 30-day mortality rate following the diagnosis of sepsis.ResultsOut of the 2175 eligible septic patients, 61.7% developed AKI. After the application of PSM, a total of 784 septic patients who developed AKI were matched in a 1:1 ratio with 784 septic patients who did not develop AKI. The overall 30-day attributable mortality of AKI was 6.6% (95% CI 2.3 ∼ 10.9%, p = 0.002). A subgroup analysis revealed that the 30-day attributable mortality rates for stage 1, stage 2, and stage 3 AKI were 0.6% (95% CI −5.9 ∼ 7.2%, p = 0.846), 4.7% (95% CI −3.1 ∼ 12.4%, p = 0.221) and 16.8% (95% CI 8.1 ∼ 25.2%, p < 0.001), respectively. Particularly noteworthy was that stage 3 AKI emerged as an independent risk factor for 30-day mortality, possessing an adjusted hazard ratio of 1.80 (95% CI 1.31 ∼ 2.47, p < 0.001).ConclusionsThe overall 30-day attributable mortality of AKI among critically ill patients with sepsis was 6.6%. Stage 3 AKI had the most significant contribution to 30-day mortality, while stage 1 and stage 2 AKI did not increase excess mortality.

Construction of a lactate-related prognostic signature for predicting prognosis after surgical repair for acute type a aortic dissection.

Background: Serum lactate is commonly measured in the perioperative period in patients who have undergone surgery for an acute type A aortic dissection (ATAAD). However, conflicting data has been reported as to whether lactate elevation is associated with short-term prognosis. The aim of the current study was to determine the association between perioperative arterial lactate levels and postoperative 30-day mortality. Methods: Patients who underwent repair of a ATAAD at our institution were retrospectively screened and those with comprehensive measurements of serum lactate before surgery and at 0, 1, 3, 6, 12, and 24h after surgery in the intensive care unit (ICU) were selected for the analysis. Patients' demographic features and outcomes were reviewed to determine risk factors associated with 30-day mortality using logistic regression modeling. The association between serum lactate levels at different time points and 30-day mortality were analyzed by receiver-operating characteristic curves. Results: 513 patients were identified and retrospectively analyzed for this study including 66 patients (12.9%) who died within 30days after surgery. Patients who died within 30 days after surgery had elevated lactate levels measured before surgery and at 0, 1, 3, 6, 12, and 24h after their ICU stay. Lactate measured at 24h post ICU admission (odds ratio, 2.131; 95% confidence interval, 1.346-3.374; p = 0.001) was a predictor of 30-day mortality. The area under the curve (AUC) for 30-day mortality with lactate levels at 12 h and 24h post ICU stay were 0.820 and 0.805, respectively. Conclusion: Early elevation of lactate level is correlated with increased 30-day mortality in patients who received ATAAD surgical repair.

Early dynamic behavior of lactate in predicting continuous renal replacement therapy after surgery for acute type A aortic dissection.

BackgroundIt has been well known that hyperlactatemia is an independent risk factor for postoperative mortality in patients who received acute type A aortic dissection (ATAAD) surgery. Some patients may require the assistance of continuous renal replacement therapy (CRRT) for acute postoperative renal deficiency and often associate with increased mortality rate. This study aimed to examine the association between the early dynamic change of lactate levels and postoperative CRRT in ATAAD patients who received surgical repairment.MethodsThis retrospective study included 503 patients who received ATAAD surgeries. Serum lactate levels were measured before operation and at 0, 1, 3, 6, 12, 24 h post intensive care unit (ICU) admission. We examined the association between dynamic changes of lactate and CRRT.ResultsAmong all patients, 19.9% (100 patients) required CRRT. Our data showed that the lactate levels were higher in the CRRT group at all timepoints compared to the non-CRRT group. In a multivariate model, lactate levels at 12 h post ICU admission [odds ratio (OR), 1.362; p = 0.007] was identified as an independent predictor for requiring CRRT. Unsurprisingly, 30-day mortality in the CRRT group (41%) was 8.2 times higher than in the non-CRRT group (5%). To better understand the associations between CRRT and lactate levels, patients in the CRRT group were further stratified into the non-survivor group (n = 41) and survivor group (n = 59) based on the 30-day mortality. Elevated lactate levels measured upon ICU admission (OR, 1.284; p = 0.001) and decreased 24 h lactate clearance (OR, 0.237; p = 0.039) were independent risk factors for 30-day mortality in patients who received CRRT. The area under the curve to predict requirement for CRRT at 6 and 12 h post CICU admission were 0.714 and 0.722, respectively, corresponding to lactate cut-off levels of 4.15 and 2.45 mmol/L.ConclusionThe CRRT is commonly required in patients who received ATAAD surgery and often associated with worse mortality. Early dynamic changes of lactate levels can be used to predict the requirement of postoperative CRRT.

Early mobilization is associated with decreased mechanical ventilation and ICU length of stay following cardiac surgery

Background: Early mobilization of the Intensive Care Unit (ICU) patients improves muscle strength and functional capacity. It has been demonstrated that prevents Intensive Care Unit Acquired Weakness (ICUAW) and accelerates ICU discharge. However, data on mobilization early after cardiac surgery are inadequate. This study aimed to record early mobilization and investigates the association with ICU findings in cardiac surgery patients.Material and Methods: In this observational study, 165 patients after cardiac surgery were enrolled. Of these, 159 were assessed for early mobilization and mobilization status during ICU stay. Mobilization practices were recorded from 1st post ICU admission and every 48 h until 7th day. The duration of mechanical ventilation (MV) support, ICU length of stay and clinical outcome were recorded from medical records registration. Results: Early mobilization consisted of active and passive limb mobilization, sitting in bed and transferring from bed to chair. The proportion of patients mobilized, was 18% (n = 29/159) on day 1, 53% (n = 46/87) on day 3, 54% (n = 22/41) on day 5 and 62% (n = 15/24) on day 7. ICU length of stay was reduced for mobilized patients (n = 29) on day 1 compared to non-mobilized ones (24 ± 10 vs 47 ± 73 h respectively, P = 0.001). The duration of MV was shorter in mobilized patients on day 3 (n =46) compared to bedridden, (18 ± 9 vs 23 ± 30 h respectively, P = 0.01).Conclusions: Early mobilization after cardiac surgery was found to be low with a significant trend to increase over ICU stay. It is also associated with a reduced duration of MV and ICU length of stay.

Longitudinal profiling of the burn patient cutaneous and gastrointestinal microbiota: a pilot study

Sepsis is a leading cause of morbidity and mortality in patients that have sustained a severe burn injury. Early detection and treatment of infections improves outcomes and understanding changes in the host microbiome following injury and during treatment may aid in burn care. The loss of functional barriers, systemic inflammation, and commensal community perturbations all contribute to a burn patient’s increased risk of infection. We sampled 10 burn patients to evaluate cutaneous microbial populations on the burn wound and corresponding spared skin on days 0, 3, 7, 14, 21, and 28 post-intensive care unit admission. In addition, skin samples were paired with perianal and rectal locations to evaluate changes in the burn patient gut microbiome following injury and treatment. We found significant (P = 0.011) reduction in alpha diversity on the burn wound compared to spared skin throughout the sampling period as well as reduction in common skin commensal bacteria such as Propionibacterium acnes and Staphylococcus epidermitis. Compared to healthy volunteers (n = 18), the burn patient spared skin also exhibited a significant reduction in alpha diversity (P = 0.001). Treatments such as systemic or topical antibiotic administration, skin grafting, and nutritional formulations also impact diversity and community composition at the sampling locations. When evaluating each subject individually, an increase in relative abundance of taxa isolated clinically by bacterial culture could be seen in 5/9 infections detected among the burn patient cohort.

Physiotherapists' perceptions of collaborations with inter-professional team members in an ICU setting.

Background In the intensive care unit (ICU) environment, inter-professional team collaborations have direct impact on patient care outcomes. Current evidence shows that providing physiotherapy to ICU patients shortens their length of stay and reduces their incidence of ventilator associated pneumonia and severity of critical illness neuropathy. Physiotherapists’ perceptions of their interactions with nurses and doctors as inter-professional team members in the ICU is important. Objectives To identify barriers and enablers of physiotherapists’ interactions with inter-professional team members in adult ICU settings, identify solutions to the barriers and determine if perceptions of interactions with ICU team members differ between junior and senior physiotherapists. Methods A qualitative study was done using semi-structured group discussions. Participants were recruited using convenience sampling. Participants were junior and senior physiotherapists from four private and four public sector hospitals in urban Johannesburg, South Africa. Interviews were audio recorded. Recordings were transcribed and direct content analysis of data was done to create categories, subcategories and themes. Results Twenty-two junior and 17 senior ICU physiotherapists participated in the study. Barriers raised by physiotherapists regarding communication with inter-professional team members in the ICU were non-ICU trained staff working in ICU, personality types, lack of professional etiquette, and frequent rotation of ICU staff. Enablers of communication with inter-professional team members were presence of team members in ICU during the day, good time management, teamwork approach to care and sharing of knowledge. Differing paradigms of teamwork among health professionals was highlighted as a cause of tension in the ICU inter-professional collaborations. Conclusion Physiotherapists are important members of the inter-professional ICU team. Exploring their interactions with other team members identified solutions that may improve collaboration between inter-professional team members to facilitate improved patient outcomes. Inter-professional education should inform ICU policies to create an environment that fosters teamwork. Finding creative ways to adequately staff the ICU without losing quality or driving up costs of care are matters that should take priority among policy makers. Contributions of the study Physiotherapists are essential and strategically placed in the ICU to reduce length of stay, and prevent patient physical function decline post ICU admission. This work explored physiotherapists’ perceptions of collaboration within inter-professional teams in the ICU and identified barriers that impede communication in inter-professional teams and suggested solutions. This research will contribute in improving collaboration between inter-professional teams in the ICU setting.

Positive fluid balance was associated with mortality in patients with acute-on-chronic liver failure: A cohort study.

We aimed to study the effect of FB in the outcomes of critically-ill patients with cirrhosis. Retrospective analysis of all adult consecutive admissions of patients with cirrhosis and organ failures to the Intensive Care Unit (ICU) at Curry Cabral Hospital (Lisbon, Portugal) and University of Alberta Hospital (Edmonton, Canada) on 08/2013-08/2017. Primary exposure was FB at 3 and 7days post ICU admission. Primary endpoint was hospital mortality. Amongst 333 patients, median age was 56years and 67.6% were men. Median MELD, APACHEII, CLIF-SOFA, and CLIF-C-ACLF scores on ICU admission were 27, 28, 14, and 54, respectively. ICU and hospital mortality rates were 33.0% and 49.2%, respectively. While median FB at 3days post ICU admission (+5.46l vs. +6.62l; P=0.74) was not associated with hospital mortality, higher median FB at 7days post ICU admission (+13.50l vs. +6.90l; P=0.036) was associated with higher hospital mortality. This association remained significant (OR 95%CI=1.04 [1.01;1.07] per each l) after adjustment for confounders (age, ascites, infection, lactate, and number of organ failures). FB may be a therapeutic target that helps to improve the outcomes of patients with acute-on-chronic liver failure. This data may inform future clinical trials.

Different Biomarker Kinetics in Critically Ill Patients with High Lactate Levels.

We evaluated the association of the kinetics of interleukin-6 (IL-6), neutrophil gelatinase-associated lipocalin (NGAL), and high-mobility group box 1 (HMGB1) with intensive care unit (ICU) mortality in critically ill patients with hyperlactatemia. This proof-of-concept study was conducted with prospectively enrolled patients admitted to a medical/surgical ICU with hyperlactatemia (lactate levels >4 mmol/L). Blood lactate, IL-6, NGAL, and HMGB1 were measured every 2 h until 6 h post ICU admission. The primary outcome was ICU mortality. Of thirty patients in this study, 14 patients (47%) had sepsis, and the ICU mortality was 47%. IL-6 and NGAL levels were significantly higher in septic patients than in non-septic patients. On kinetic analysis, the lactate levels were significantly decreased in survivors, and the NGAL levels were significantly increased in non-survivors. Among septic patients, a decline in IL-6 levels were observed in survivors. The HMGB1 levels were unchanged in survivors and non-survivors regardless of sepsis complication. Non-septic patients with higher reduction rate of lactate and HMGB1 had the lowest mortality than the others. ICU patients exhibited different kinetic patterns in lactate, NGAL, and IL-6, but HMGB1 did not seem to change over the 6-h duration. Further studies are necessary to evaluate the efficacy of the combination of the inflammatory biomarkers with lactate.

Incidence and predisposing factors for the development of disturbed glucose metabolism and DIabetes mellitus AFter Intensive Care admission: the DIAFIC study.

IntroductionElevated blood glucose levels during intensive care unit (ICU) stay, so-called stress hyperglycaemia (SH), is a common finding. Its relation with a future diabetes risk is unclear. Our objective was to determine the incidence of disturbed glucose metabolism (DGM) post ICU admission and to identify predictors for future diabetes risk with a focus on stress hyperglycaemia.MethodsThis single center prospective cohort trial (DIAFIC trial) had a study period between September 2011 and March 2013, with follow-up until December 2013. The setting was a mixed medical/surgical ICU in a tertiary teaching hospital in Belgium. 338 patients without known diabetes mellitus were included for analysis. We assessed the level of glucose metabolism disturbance (as diagnosed with a 75 g oral glucose tolerance test (OGTT) and/or HbA1c level) eight months after ICU admission, and investigated possible predictors including stress hyperglycaemia.ResultsIn total 246 patients (73 %) experienced stress hyperglycaemia during the ICU stay. Eight months post-ICU admission, 119 (35 %) subjects had a disturbed glucose metabolism, including 24 (7 %) patients who were diagnosed with diabetes mellitus. A disturbed glucose metabolism tended to be more prevalent in subjects who experienced stress hyperglycaemia during ICU stay as compared to those without stress hyperglycaemia (38 % vs. 28 %, P = 0.065). HbA1c on admission correlated with the degree of stress hyperglycaemia. A diabetes risk score (FINDRISC) (11.0 versus 9.5, P = 0.001), the SAPS3 score (median of 42 in both groups, P = 0.003) and daily caloric intake during ICU stay (197 vs. 222, P = 0.011) were independently associated with a disturbed glucose metabolism.ConclusionsStress hyperglycaemia is frequent in non-diabetic patients and predicts a tendency towards disturbances in glucose metabolism and diabetes mellitus. Clinically relevant predictors of elevated risk included a high FINDRISC score and a high SAPS3 score. These predictors can provide an efficient, quick and inexpensive way to identify patients at risk for a disturbed glucose metabolism or diabetes, and could facilitate prevention and early treatment.Trial registrationAt ClinicalTrials.gov NCT02180555. Registered 1 July, 2014.

Prevalence of glutamine deficiency in ICU patients: a cross-sectional analytical study.

BackgroundNot only is glutamine deficiency an independent predictor of mortality in intensive care unit (ICU) patients, but glutamine supplementation is also recommended for its proven outcome benefits. However, recent data suggest that early glutamine supplementation in certain patient groups increase mortality. The aim of this study was to investigate plasma glutamine levels of adult ICU patients in the South African setting and to determine relationships between glutamine levels, gender, diagnostic categories and selected inflammatory markers. The data from this study will be used as baseline measurement to support a large scale study that will be undertaken in the South African ICU population.MethodsThis cross-sectional, analytical study included 60 mixed adult ICU patients within 24 h post ICU admission. Plasma glutamine levels were determined on admission. The relationship between glutamine levels, Interleukin-6 (IL-6) and C-reactive protein (CRP); as well as gender- and diagnosis-related differences in glutamine levels were also investigated. A non-parametric ROC curve was computed to determine the CRP concentration cut-off point above which glutamine becomes deficient.ResultsThe median plasma glutamine level (497 μmol/L) was in the normal range; however, 38.3 % (n = 23) of patients had deficient (<420 μmol/L) and 6.7 % (n = 4) had supra-normal glutamine levels (>930 μmol/L). No significant difference could be detected between glutamine levels and gender or diagnosis categories as a group. When only the medical and surgical categories were compared, the median plasma glutamine level of the medical patients were significantly lower than that of the surgical patients (p = 0.042). Glutamine showed inverse associations with CRP levels (r = −0.44, p < 0.05) and IL-6 concentrations (r = −0.23, p = 0.08). A CRP cut-off value of 95.5 mg/L was determined above which glutamine levels became deficient.ConclusionsAbout a third of patients (38 %) were glutamine deficient on admission to ICU, whereas some presented with supra-normal levels. While glutamine levels correlated inversely with inflammatory markers, and a CRP value of above 95.5 mg/L indicated potential glutamine deficiency, the clinical application of this finding needs further investigation.

Development of a daily mortality probability prediction model from Intensive Care Unit patients using a discrete-time event history analysis

As studies have pointed out, severity scores are imperfect at predicting individual clinical chance of survival. The clinical condition and pathophysiological status of these patients in the Intensive Care Unit might differ from or be more complicated than most predictive models account for. In addition, as the pathophysiological status changes over time, the likelihood of survival day by day will vary. Actually, it would decrease over time and a single prediction value cannot address this truth. Clearly, alternative models and refinements are warranted. In this study, we used discrete-time-event models with the changes of clinical variables, including blood cell counts, to predict daily probability of mortality in individual patients from day 3 to day 28 post Intensive Care Unit admission. Both models we built exhibited good discrimination in the training (overall area under ROC curve: 0.80 and 0.79, respectively) and validation cohorts (overall area under ROC curve: 0.78 and 0.76, respectively) to predict daily ICU mortality. The paper describes the methodology, the development process and the content of the models, and discusses the possibility of them to serve as the foundation of a new bedside advisory or alarm system.

La récupération des agents anesthésiques volatils dans l’environnement de l’unité des soins intensifs cardiovasculaires: un rapport technique

The use of volatile-based sedation within critical care environments has been limited by difficulties of drug administration and safety concerns over environment pollution and staff exposure in an intensive care unit (ICU) with no scavenging. The aim of this study was to develop a simple scavenging system to be used with the Anesthesia Conserving Device (AnaConDa(®)) and to determine whether or not ambient concentrations of residual anesthetic are within current acceptable limits. The scavenging system consists of two Deltasorb(®) canisters attached to the ICU ventilator in series. AnaConDa is a miniature vaporizer designed to provide volatile-based sedation within an ICU. The first ten patients recruited into a larger randomized trial assessing outcomes after elective coronary graft bypass surgery were sedated within the cardiac ICU using either isoflurane or sevoflurane. Sedation was guided by the Sedation Agitation Scale, resulting in an end-tidal minimum anesthetic concentration of volatile agent ranging from 0.1-0.3. At one hour post ICU admission, infrared photometric analysis was used to assess environmental contamination at four points along the ventilator circuit and scavenging system and around the patient's head. All measurements taken within the patient's room were below 1 part per million, which satisfies criteria for occupational exposure. This study shows that volatile agents can be administered safely within critical care settings using a simple scavenging system. Our scavenging system used in conjunction with the AnaConDa device reduced the concentration of environmental contamination to a level that is acceptable to Canadian standards and standards in most Western countries and thus conforms to international safety standards. The related clinical trial was registered at www.clinicaltrials.gov (NCT01151254).

Prolonged Central Venous Desaturation Measured by Continuous Oximetry is Associated With Adverse Outcomes in Pediatric Cardiac Surgery

BACKGROUND The role of continuous central venous oxygen saturation (ScvO₂) oximetry during pediatric cardiac surgery for predicting adverse outcomes is not known. Using a recently available continuous ScvO₂ oximetry catheter, we examined the association between venous oxygen desaturations and patient outcomes. We hypothesized that central venous oxygen desaturations are associated with adverse clinical outcomes. METHODS Fifty-four pediatric patients undergoing cardiac surgery were prospectively enrolled in an unblinded observational study. ScvO₂ was measured continuously in the operating room and for up to 24 h post-Intensive Care Unit admission. The relationships between ScvO₂ desaturations, clinical outcomes, and major adverse events were determined. RESULTS More than 18 min of venous saturations less than 40% were associated with major adverse events with 100% sensitivity and 97.6% specificity. Significant correlations resulted between the ScvO₂ area under the curve less than 40% and creatinine clearance at 12 h in the Intensive Care Unit (r = -0.58), Intensive Care Unit length of stay (r = 0.56), max inotrope use (r = 0.52), inotrope use at 24 h (r = 0.40), inotrope index score (r = 0.39), hospital length of stay (r = 0.36), and length of intubation (r = 0.32). CONCLUSIONS We demonstrate that ScvO₂ desaturations by continuous oximetry are associated with major adverse events in pediatric patients undergoing cardiac surgery. The most significant associations with major adverse events are seen in patients with greater than 18 min of central venous saturations less than 40%. Our results support the further investigation of ScvO₂ as a potential target parameter in high-risk pediatric patients to minimize the risk of major adverse events.

Prolonged Central Venous Desaturation Measured by Continuous Oximetry Is Associated with Adverse Outcomes in Pediatric Cardiac Surgery

The role of continuous central venous oxygen saturation (ScvO₂) oximetry during pediatric cardiac surgery for predicting adverse outcomes is not known. Using a recently available continuous ScvO₂ oximetry catheter, we examined the association between venous oxygen desaturations and patient outcomes. We hypothesized that central venous oxygen desaturations are associated with adverse clinical outcomes. Fifty-four pediatric patients undergoing cardiac surgery were prospectively enrolled in an unblinded observational study. ScvO₂ was measured continuously in the operating room and for up to 24 h post-Intensive Care Unit admission. The relationships between ScvO₂ desaturations, clinical outcomes, and major adverse events were determined. More than 18 min of venous saturations less than 40% were associated with major adverse events with 100% sensitivity and 97.6% specificity. Significant correlations resulted between the ScvO₂ area under the curve less than 40% and creatinine clearance at 12 h in the Intensive Care Unit (r = -0.58), Intensive Care Unit length of stay (r = 0.56), max inotrope use (r = 0.52), inotrope use at 24 h (r = 0.40), inotrope index score (r = 0.39), hospital length of stay (r = 0.36), and length of intubation (r = 0.32). We demonstrate that ScvO₂ desaturations by continuous oximetry are associated with major adverse events in pediatric patients undergoing cardiac surgery. The most significant associations with major adverse events are seen in patients with greater than 18 min of central venous saturations less than 40%. Our results support the further investigation of ScvO₂ as a potential target parameter in high-risk pediatric patients to minimize the risk of major adverse events.

Serum lactate is not predicted by anion gap or base excess after trauma resuscitation.

The inability to normalize lactate predicts death after trauma, but lactate may not be immediately available in every center. We postulated that, in a normal acid-base environment, lactate would correlate with the anion gap and the base excess of an arterial blood gas. We studied 52 consecutive, invasively monitored patients with trauma admitted directly to the intensive care unit (ICU) from the emergency department or operating room in our level I center to determine whether base excess and anion gap could predict lactate. Lactate, base excess, and anion gap were recorded upon admission to the ICU and 8, 16, 24, 36, and 48 hours after admission. Correlation coefficients (r2) were calculated for the total patients, the 43 survivors, and the nine non-survivors. Serum lactate was significantly higher in nonsurvivors at 16 hours after post ICU admission (4.0 +/- 1.69 vs. 2.84 +/- 1.49, p < 0.05), and this trend persisted; the greatest difference was seen at 48 hours after admission (2.92 +/- 1.47 vs. 1.76 +/- 0.57, p < 0.001). There were no differences in base excess or anion gap between survivors and nonsurvivors. We found no consistent correlation between lactate versus anion gap, lactate versus base excess, or anion gap versus base excess. There is no correlation between lactate, base excess, and anion gap after initial resuscitation. Neither anion gap nor base excess was capable of predicting lactate; therefore, lactate must be directly measured. The lack of correlation of anion gap with base excess or lactate suggests the presence of unmeasured anions, an impairment in acid-base regulation after injury and resuscitation, or both.