Reason For Intensive Care Unit Admission Research Articles

Exploring intensivist involvement: Patient characteristics, interventions and outcomes.

Intensivists play a critical role in the management of intensive care units (ICUs) and in providing high quality care. While international guidelines recommend intensivist staffing for improved patient outcomes, there is a shortage of qualified intensivists in many regions, including Türkiye. This study aimed to assess the impact of introducing a full-time intensivist to a medical ICU on patient characteristics, outcomes, and ICU interventions. This retrospective study analyzed data from the Internal Medicine ICU at Van Yüzüncü Yıl University Dursun Odabaş Medical Center over two periods: Pre- and post-intensivist recruitment. The study included adult patients admitted to the ICU from February 2018 to January 2020. Patient demographics, reasons for ICU admission, APACHE-II and SOFA scores, ICU interventions, and outcomes were recorded and compared between the two periods. Of the 868 patients admitted during the study period, 820 were included in the analysis. There were no significant differences in demographic characteristics between the pre- and post-intensivist periods. However, patients in the post-intensivist period had higher APACHE-II and SOFA scores. Intensive care units mortality rates were comparable between the two periods. The post-intensivist period saw increased use of invasive mechanical ventilation and non-invasive ventilation compared to the pre-intensivist period. Renal replacement therapy usage and enteral nutrition provision also increased in the post-intensivist period. ICU and hospital lengths of stay remained similar between the two periods. The introduction of a full-time intensivist to the medical ICU led to changes in ICU interventions, including increased use of mechanical ventilation and renal replacement therapy. Despite these changes, ICU mortality rates remained unchanged. Further research is needed to explore the longterm impact of intensivist staffing on patient outcomes in Türkiye.

Dual-Energy CT muscle fat fraction as a new imaging biomarker of body composition and survival predictor in critically ill patients.

To analyze changes in the muscular fat fraction (FF) during immobilization at the intensive care unit (ICU) using dual-energy CT (DECT) and evaluate the predictive value of the DECT FF as a new imaging biomarker for morbidity and survival. Immobilized ICU patients (n = 81, 43.2% female, 60.3 ± 12.7 years) were included, who received two dual-source DECT scans (CT1, CT2) within a minimum interval of 10 days between 11/2019 and 09/2022. The DECT FF was quantified for the posterior paraspinal muscleby two radiologists using material decomposition. The skeletal muscle index (SMI), muscle radiodensity attenuation (MRA), subcutaneous-/ visceral adipose tissue area (SAT, VAT), and waist circumference (WC) were assessed. Reasons for ICU admission, clinical scoring systems, therapeutic regimes, and in-hospital mortality were noted. Linear mixed models, Cox regression, and intraclass correlation coefficients were employed. Between CT1 and CT2 (median 21 days), the DECT FF increased (from 20.9% ± 12.0 to 27.0% ± 12.0, p = 0.001). The SMI decreased (35.7 cm2/m2 ± 8.8 to 31.1 cm2/m2 ± 7.6, p < 0.001) as did the MRA (29HU ± 10 to 26HU ± 11, p = 0.009). WC, SAT, and VAT did not change. In-hospital mortality was 61.5%. In multivariable analyses, only the change in DECT FF was associated with in-hospital mortality (hazard ratio (HR) 9.20 [1.78-47.71], p = 0.008), renal replacement therapy (HR 48.67 [9.18-258.09], p < 0.001), and tracheotomy at ICU (HR 37.22 [5.66-245.02], p < 0.001). Inter-observer reproducibility of DECT FF measurements was excellent (CT1: 0.98 [0.97; 0.99], CT2: 0.99 [0.96-0.99]). The DECT FF appears to be suitable for detecting increasing myosteatosis. It seems to have predictive value as a new imaging biomarker for ICU patients. The dual-energy CT muscular fat fraction appears to be a robust imaging biomarker to detect and monitor myosteatosis. It has potential for prognosticating, risk stratifying, and thereby guiding therapeutic nutritional regimes and physiotherapy in critically ill patients. The dual-energy CT muscular fat fraction detects increasing myosteatosis caused by immobilization. Change in dual-energy CT muscular fat fraction was a predictor of in-hospital morbidity and mortality. Dual-energy CT muscular fat fraction had a predictive value superior to establishedCT body composition parameters.

Risk of acute kidney injury in critically-ill patients with COVID-19 compared with seasonal influenza: a retrospective cohort study

The SARS-CoV-2 virus can bind to angiotensin-converting enzyme 2 receptors on host renal cells and may cause acute kidney injury (AKI). The comparative risks of AKI in patients severely ill with COVID-19 and influenza A have not been examined. This is a retrospective cohort study including patients with positive PCR results for SARS-CoV-2 or influenza A virus admitted to the intensive care units (ICUs) of 15 public hospitals in Hong Kong between 1st January 2013 and 30th April 2023. Patients who were already on chronic dialysis or had missing values in the confounder model were excluded. Data were retrieved from Hong Kong Hospital Authority's electronic healthcare records. The primary outcome was incident AKI during ICU stay. Secondary outcomes included acute kidney disease (AKD) and hospital mortality. All analyses were examined in multivariable regression adjusting for potential confounders (age, sex, baseline eGFR, PaO2/FiO2 ratio, baseline comorbidities, APACHE IV predicted risk of death, Charlson Comorbidity Index, emergent hospital admission, admission from elderly home, reason for ICU admission, presence of bacterial co-infections, use of medications [including vasopressors, antiviral medications, steroids and nephrotoxic antibiotics], as well as anaemia and leucocytosis). Patients were matched in a 1:1 ratio using a propensity score generated based on the full confounder model. The analyses were repeated using inverse probability weighting and in propensity-score matched cohorts. A total of 5495 ICU patients were identified. After excluding 1093 (19.9%) patients who met the exclusion criteria and 74 (1.3%) patients who had one or more missing values in the logistic regression model, a total of 4328 patients were included in the final analysis, with 2787 (64.4%) patients who tested positive for SARS-CoV-2 reverse transcription (RT)-PCR and 1541 (35.6%) patients who tested positive for influenza A virus RT-PCR. The comorbidity burden was greater in patients with COVID-19 (Charlson Comorbidity Index 3 [2-4] vs. 3 [1-4]), but the median APACHE IV predicted risk of death was significantly lower (0.19 [0.08-0.38] vs. 0.25 [0.11-0.52]). A total of 1053 (37.8%) patients with COVID-19 and 828 (53.7%) patients with influenza A developed AKI of any stage during ICU stay. In adjusted analysis, the risk of AKI was significantly lower in patients with COVID-19 compared with influenza A (adjusted odds ratio 0.51, 95% confidence interval 0.42-0.61, P<0.0001]. The risk of stage 3 AKI and AKD were also significantly lower in patients with COVID-19. These results remained robust in multiple pre-planned sensitivity analyses including inverse probability weighting and propensity score matching. Our results suggest that the risk of AKI in patients severely ill with COVID-19 was lower than in patients with influenza A. The burden of concurrent organ failure complicating respiratory viral infections, such as the higher disease-attributable risk of AKI associated with influenza, should be clarified. An unrestricted philanthropic donation from Mr and Mrs Laurence Tse, The Wai Im Charitable Foundation, Chan Sui Kau Family Benefits and Charitable Foundation, So Ka Wing and Lee Sau Ying Charitable Foundation, Mr & Mrs Tam Wing Fun Edmund Renal Research Fund, the Theme-Based Research Scheme of the Research Grants Council, Hong Kong Special Administrative Region, The Government of the Hong Kong Special Administrative Region; Programme of Enhancing Laboratory Surveillance and Investigation of Emerging Infectious Diseases and Antimicrobial Resistance for the Department of Health of the Hong Kong Special Administrative Region Government; Emergency COVID-19 Project, Major Projects on Public Security, National Key Research and Development Program; Emergency Collaborative Project of Guangzhou Laboratory; the National Key Research and Development Program of China; Sanming Project of Medicine in Shenzhen China; and the High Level-Hospital Program, Health Commission of Guangdong Province, China.

The association of the Sequential Organ Failure Assessment score at intensive care unit discharge with intensive care unit readmission in the cardiac intensive care unit.

Unplanned intensive care unit (ICU) readmissions contribute to increased morbidity, mortality, and healthcare costs. The severity of patient illness at ICU discharge may predict early ICU readmission. Thus, in this study, we investigated the association of cardiac ICU (CICU) discharge Sequential Organ Failure Assessment (SOFA) score with unplanned CICU readmission in patients admitted to the CICU. We retrospectively reviewed the hospital medical records of 4659 patients who were admitted to the CICU from 2012 to 18. Sequential Organ Failure Assessment scores at CICU admission and discharge were obtained. The predictive performance of organ failure scoring was evaluated by using area under the receiver operating characteristic (AUROC) curves. The primary outcome was unplanned CICU readmission. Of the 3949 patients successfully discharged from the CICU, 184 (4.7%) had an unplanned CICU readmission or they experienced a deteriorated condition but died without being readmitted to the CICU (readmission group). The readmission group had significantly higher rates of organ failure in all organ systems at both CICU admission and discharge than the non-readmission group. The AUROC of the discharge SOFA score for CICU readmission was 0.731, showing good predictive performance. The AUROC of the discharge SOFA score was significantly greater than that of either the initial SOFA score (P = 0.020) or the Acute Physiology and Chronic Health Evaluation II score (P < 0.001). In the multivariable regression analysis, SOFA score, overweight or obese status, history of heart failure, and acute heart failure as reasons for ICU admission were independent predictors of unplanned ICU readmission during the same hospital stay. The discharge SOFA score may identify patients at a higher risk of unplanned CICU readmission, enabling targeted interventions to reduce readmission rates and improve patient outcomes.

Prognosis of lung cancer patients followed in the intensive care unit: A cross-sectional study

Lung cancer is the most common solid organ malignancy requiring intensive care unit (ICU) admission. For many years, lung cancer patients were not considered in the priority patient category for admission to ICU because of their high mortality rate and poor response to therapy. Considering the developments in treatment modalities, we aimed to reevaluate the prognosis of patients with lung cancer in the ICU. Patients characteristics, date of diagnosis, the reason for ICU admission, the stage of cancer, histopathological type, history of chemotherapy, radiotherapy, or surgery for cancer, and APACHE-II and Charlson comorbidity index (CCI) were recorded retrospectively. A total of 100 patients had a mean age of 69.7 ± 9.0 years. Among these patients, 18% had small cell lung cancer, while 82% had non-small cell lung cancer. The in-hospital mortality rate was 69% for all patients, while among those discharged from the ICU, the first 6-month mortality rate was 58.1%. The median survival time was 8.2 months. Advanced age, the need for mechanical ventilation, the need for vasopressors, a high APACHE -II, and the CCI all reduced survival in multivariate analysis, whereas chemotherapy and surgical history improved survival. Patients admitted to the ICU with lung cancer continue to experience a high mortality rate. However, identifying the factors that are associated with survival can be crucial in establishing care plans and prioritizing ICU admission for further therapy.

Comparison of the healthcare-associated infections in intensive care units in Turkey before and during COVID-19

BackgroundSecondary bacterial infections are an important cause of mortality in patients with coronavirus disease 2019 (COVID-19). All healthcare providers acted with utmost care with the reflex of protecting themselves during the COVID-19 period. We aimed to compare the rates of ventilator-associated pneumonia (VAP) and bloodstream infections (BSIs) in our intensive care units (ICUs) before and during the COVID-19 outbreak surges.MethodsThis multicenter, retrospective, cross-sectional study was performed in six centers in Turkey. We collected the patient demographic characteristics, comorbidities, reasons for ICU admission, mortality and morbidity scores at ICU admission, and laboratory test data.ResultsA total of 558 patients who required intensive care from six centers were included in the study. Four hundred twenty-two of these patients (males (62%), whose mean age was 70 [IQR, 58–79] years) were followed up in the COVID period, and 136 (males (57%), whose mean age was 73 [IQR, 61–82] years) were followed up in the pre-COVID period. BSI and VAP rates were 20.7 (19 events in 916 patient days) and 17 (74 events in 4361 patient days) with a −3.8 difference (P = 0.463), and 33.7 (31 events in 919 patient days) and 34.6 (93 events in 2685 patient days) with a 0.9 difference (P = 0.897), respectively. The mortality rates were 71 (52%) in pre-COVID and 291 (69%) in COVID periods.ConclusionProtective measures that prioritize healthcare workers rather than patients and exceed standard measures made no difference in terms of reducing mortality.

Risk factors for ICU mortality in patients with hematological malignancies: a singlecenter, retrospective cohort study from Turkey.

Patients with hematological malignancies (HM) often require admission to the intensive care unit (ICU) due to organ failure, disease progression or treatment-related complications, and they generally have a poor prognosis. Therefore, understanding the factors affecting ICU mortality in HM patients is important. In this study, we aimed to identify the risk factors for ICU mortality in our critically ill HM patients. We retrospectively reviewed the medical records of HM patients who were hospitalized in our medical ICU between January 1, 2010 and December 31, 2018. We recorded some parameters of these patients and compared these parameters by statistically between survivors and nonsurvivors to determine the risk factors for ICU mortality. The study included 368 critically ill HM patients who were admitted to our medical ICU during a 9-year period. The median age was 58 (49-67) years and 63.3% of the patients were male. Most of the patients (43.2%) had acute leukemia. Hematopoietic stem cell transplantation (HSCT) was performed in 153 (41.6%) patients. The ICU mortality rate was 51.4%. According to univariable analyses, a lot of parameters (e.g., admission APACHE II and SOFA scores, length of ICU stay, some laboratory parameters at the ICU admission, the reason for ICU admission, comorbidities, type of HM, type of HSCT, infections on ICU admission and during ICU stay, etc.) were significantly different between survivors and nonsurvivors. However, only high SOFA scores at ICU admission (OR:1.281, p = 0.004), presence of septic shock (OR:17.123, p = 0.0001), acute kidney injury (OR:48.284, p = 0.0001), and requirement of invasive mechanical ventilation support during ICU stay (OR:23.118, p = 0.0001) were independent risk factors for ICU mortality. In our cohort, critically ill HM patients had high ICU mortality. We found four independent predictors for ICU mortality. Yet, there is still a need for further research to better understand poor outcome predictors in critically ill HM patients.

Risk factors for peripheral venous catheter-related phlebitis stratified by body mass index in critically ill patients: A post-hoc analysis of the AMOR-VENUS study.

Phlebitis is an important complication in patients with peripheral intravascular catheters (PIVCs). Although an association between body mass index (BMI) and phlebitis has been suggested, the risk of phlebitis according to BMI has not been well elucidated. Therefore, in this study, we analyzed the risk of phlebitis according to BMI in patients in the intensive care unit (ICU). This study undertook a secondary analysis of the data from a prospective multicenter observational study assessing the epidemiology of phlebitis at 23 ICUs in Japan. Patients admitted into the ICU aged ≥18 years with a new PIVC inserted after ICU admission were consecutively enrolled and stratified into the following groups based on BMI: Underweight (BMI < 18.5 kg/m2), normal weight (18.5 ≤ BMI < 25.0 kg/m2), and overweight/obese (BMI ≥ 25.0 kg/m2). The primary outcome was phlebitis. The risk factors for phlebitis in each BMI-based group were investigated using a marginal Cox regression model. In addition, hazard ratios and 95% confidence intervals were calculated. A total of 1,357 patients and 3,425 PIVCs were included in the analysis. The mean BMI for all included patients was 22.8 (standard deviation 4.3) kg/m2. Among the eligible PIVCs, 455; 2,041; and 929 were categorized as underweight, normal weight, and overweight/obese, respectively. In the underweight group, catheter size ≥ 18 G and amiodarone administration were independently associated with the incidence of phlebitis. Drug administration standardization was associated with the reduction of phlebitis. In the normal weight group, elective surgery as a reason for ICU admission, and nicardipine, noradrenaline, and levetiracetam administration were independently associated with the incidence of phlebitis. Heparin administration was associated with the reduction of phlebitis. In the overweight/obese group, the Charlson comorbidity index, catheter size ≥ 18 G, and levetiracetam administration were independently associated with the incidence of phlebitis. Catheters made from PEU-Vialon (polyetherurethane without leachable additives) and tetrafluoroethylene were associated with the reduction of phlebitis. We investigated the risk factors for peripheral phlebitis according to BMI in ICU and observed different risk factors in groups stratified by BMI. For example, in underweight or overweight patients, large size PIVCs could be avoided. Focusing on the various risk factors for phlebitis according to patients' BMIs may aid the prevention of phlebitis.

The role of the clinical pharmacist in the prevention of drug-induced acute kidney injury in the intensive care unit.

Acute kidney injury (AKI) is a disorder that is commonly seen in patients in the intensive care unit (ICU) and has a detrimental impact on the patients' clinical prognosis. Although a variety of factors contribute to the development of AKI in patients, drug-induced AKI is a common occurrence in the ICU. With the widespread availability of clinical pharmacy services, the clinical pharmacist's consultation service to the healthcare team aids in the resolution of drug-related issues and the enhancement of therapeutic outcomes. The involvement of a clinical pharmacist in the ICU team is expected to minimize the incidence of drug-induced AKI and enhance therapeutic results. Therefore, the goal of our study was to demonstrate the impact of having a clinical pharmacist on the occurrence, stages, and treatment of AKI. The study included two patient groups: intervention (n=75) (IG) and control (n=75) (CG) groups. The clinical pharmacist has made recommendations to the ICU team regarding the treatment of IG patients on drug selection, drug administration routes, drug dose adjustment, drug-drug interactions, drug-food or nutritional solution interactions, drug side effect management, and drug incompatibility. No interventions were provided by the clinical pharmacist in the CG patients. The clinical pharmacist visited patients regularly and noted the laboratory findings and pharmacological treatments of patients in the study groups on the patient follow-up forms. The obtained data of IG and CG were compared and statistical methods were used to assess them. According to our findings, AKI was found to be more common in CG than in IG (p < 0.05). Stage 1 was shown to be the most common AKI stage in the patients (p > 0.05). The gap between the patients' highest Cr and basal sCr values was less in IG (p < 0.05). When the association between reasons for ICU admission and AKI was investigated, pulmonary edema and acute respiratory failure were found to have a significant and positive relationship with AKI (p < 0.05). Furthermore, it was shown that patients with diabetes and cancer comorbidities were the most vulnerable to developing AKI (p < 0.05). Antibiotics, anaesthetics, and cardiovascular system medication categories were found to have a significant and positive correlation with AKI in patients (p < 0.05). Also, it was revealed that the usage of vancomycin, colistin, ampicillin-sulbactam, clarithromycin, ceftriaxone, midazolam, and dexketoprofen caused AKI (p < 0.05). Our findings demonstrate that if a clinical pharmacist is included in the ICU team and provides consultation services to the ICU team regarding patient treatment by performing regular patient follow-up, the incidence of AKI in patients can be minimized and therapeutic outcomes can be improved.

Role of the intensive care in allogeneic hematopoietic stem cell transplantation

Introduction. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is often complicated by life-threatening conditions.Aim — an analysis of the life-threatening complications in recipients of allogeneic hematopoietic stem cells (allo-HSCs)Main findings. From 10 to 50 % of allo-HSC recipients need to be admitted to the intensive care unit (ICU) due to the development of life-threatening complications. The reasons for ICU admission are acute respiratory failure, sepsis, graft-versus-host disease, veno-occlusive disease, thrombotic microangiopathy, cytokine release syndrome, engraftment syndrome, etc. Conditioning regimen, donor type, stem cell source, underlying disease state and patient comorbidity are the risk factors associated with development of life-threatening conditions. The main prognostic factors of unfavorable ICU outcomes in allo-HSC recipients are the severity of multiple organ dysfunction and the need for organ support.

Cocreating the ICU-PAUSE Tool for Intensive Care Unit-Ward Transitions.

BackgroundIntensive care unit (ICU)–ward patient transfers are inherently high risk, and clinician miscommunication has been linked to adverse events and negative outcomes. Despite these risks, few educational tools exist to improve resident handoff communication at ICU–ward transfer.ObjectiveWe used human-centered design (HCD) methods to cocreate a novel electronic health record ICU–ward transfer tool alongside Internal Medicine residents at three academic hospitals.MethodsWe conducted HCD workshops at each hospital, performing process mapping, brainstorming, and rapid prototyping. We performed thematic analysis on verbatim-transcribed workshop audio recordings to inform development and adaptation of the final resident prototype into the ICU-PAUSE tool.ResultsICU-PAUSE focuses on reasons for ICU admission and problem-based ICU course (I); Code status, goals of care, and family contacts (C); a diagnostic pause acknowledging Uncertainty (U); Pending tests (P); Active consultants (A); high-risk medications, including medications to be Unprescribed (U); Summary of problems and to-dos (S); and a current physical Exam (E).ConclusionWe used HCD to cocreate a novel, more user-friendly electronic ICU–ward transfer tool, ICU-PAUSE, alongside Internal Medicine trainees. Future steps will involve formal usability testing, evidence-driven implementation, and clinical evaluation of ICU-PAUSE across multiple hospitals.

Acute ischemic stroke in a university hospital intensive care unit: 1-year costs and outcome.

Background and purposeLittle is currently known about the cost‐effectiveness of intensive care of acute ischemic stroke (AIS). We evaluated 1‐year costs and outcome for patients with AIS treated in the intensive care unit (ICU).Materials and methodsA single‐center retrospective study of patients admitted to an academic ICU with AIS between 2003 and 2013. True healthcare expenditure was obtained up to 1 year after admission and adjusted to consumer price index of 2019. Patient outcome was 12‐month functional outcome and mortality. We used multivariate logistic regression analysis to identify independent predictors of favorable outcomes and linear regression analysis to assess factors associated with costs. We calculated the effective cost per survivor (ECPS) and effective cost per favorable outcome (ECPFO).ResultsThe study population comprised 154 patients. Reasons for ICU admission were: decreased consciousness level (47%) and need for respiratory support (40%). There were 68 (44%) 1 year survivors, of which 27 (18%) had a favorable outcome. High age (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.91–0.98) and high hospital admission National Institutes of Health Stroke Scale score (OR 0.92, 95% CI 0.87–0.97) were independent predictors of poor outcomes. Increased age had a cost ratio of 0.98 (95% CI 0.97–0.99) per added year. The ECPS and ECPFO were 115,628€ and 291,210€, respectively.ConclusionsTreatment of AIS in the ICU is resource‐intense, and in an era predating mechanical thrombectomy the outcome is often poor, suggesting a need for further research into cost‐efficacy of ICU care for AIS patients.

A ten-year review of indications and outcomes of obstetric admissions to an intensive care unit in a low-resource country.

Obstetric intensive care unit admission (ICU) suggests severe morbidity. However, there is no available data on the subject in Ghana. This retrospective review was conducted to determine the indications for obstetric ICU admission, their outcomes and factors influencing these outcomes to aid continuous quality improvement in obstetric care. This was a retrospective review conducted in a tertiary hospital in Ghana. Data on participant characteristics including age and whether participant was intubated were collected from patient records for all obstetric ICU admissions from 1st January 2010 to 31st December 2019. Descriptive statistics were presented as frequencies, proportions and charts. Hazard ratios were generated for relations between obstetric ICU admission outcome and participant characteristics. A p-value <0.05 was deemed statistically significant. There were 443 obstetric ICU admissions over the review period making up 25.7% of all ICU admissions. The commonest indications for obstetric ICU admissions were hypertensive disorders of pregnancy (70.4%, n = 312/443), hemorrhage (14.4%, n = 64/443) and sepsis (9.3%, n = 41/443). The case fatality rates for hypertension, hemorrhage, and sepsis were 17.6%, 37.5%, and 63.4% respectively. The obstetric ICU mortality rate was 26% (115/443) over the review period. Age ≥25 years and a need for mechanical ventilation carried increased mortality risks following ICU admission while surgery in the index pregnancy was associated with a reduced risk of death. Hypertension, haemorrhage and sepsis are the leading indications for obstetric ICU admissions. Thus, preeclampsia screening and prevention, as well as intensifying antenatal education on the danger signs of pregnancy can minimize obstetric complications. The establishment of an obstetric HDU in CCTH and the strengthening of communication between specialists and the healthcare providers in the lower facilities, are also essential for improved pregnancy outcomes. Further studies are needed to better appreciate the wider issues underlying obstetric ICU admission outcomes. This was a review of the reasons for admitting severely-ill pregnant women and women who had delivered within the past 42 days to the intensive care unit (ICU), the admission outcomes and risk factors associated with ICU mortality in a tertiary hospital in a low-resource country. High blood pressure and its complications, bleeding and severe infections were observed as the three most significant reasons for ICU admissions in decreasing order of significance. Pre-existing medical conditions and those arising as a result of, or aggravated by pregnancy; obstructed labour and post-operative monitoring were the other reasons for ICU admission over the study period. Overall, 26% of the admitted patients died at the ICU and maternal age of at least 25 years and the need for intubation were identified as risk factors for ICU deaths. Attention must be paid to high blood pressure during pregnancy.

Candida spp. isolation from critically ill patients' respiratory tract. Does antifungal treatment affect survival?

Isolation of Candida spp. from bronchial samples of patients on mechanical ventilation is common. Even though it may not always reflect infection, it may induce immunological changes that can facilitate bacterial pneumonia. In this case, antifungal treatment is of uncertain value. This study examined the impact of antifungal treatment on the outcome of intensive care unit (ICU)-acquired respiratory tract infection (RTI) of critically ill, immunocompetent patients, with Candida isolation from their respiratory tract. This is a retrospective cohort study of adult patients hospitalized in the ICU of the University Hospital of Heraklion, Greece, from 2014 through 2016 with ICU-acquired RTI and Candida spp. isolated from their bronchial secretions. Data regarding medical history, demographics (gender, age), reason for ICU admission, previous antimicrobial use or hospitalization, SOFA and APACHE II score, clinical outcomes (primary clinical outcome: overall mortality during hospitalization; secondary clinical outcome: mortality during the ICU stay and duration of ICU and hospital stay) at the end of their ICU stay and at the end of their hospital stay were recorded and consequently evaluated. A logistic regression analysis model evaluated the effect of the recorded parameters in association with ICU mortality and overall mortality during hospitalization. A total of 90 individuals were enrolled. Of them, 47 (52.2%) were treated with antifungals during their hospitalization around the time of Candida isolation. Patients treated with antifungals had higher SOFA and APACHE II scores, longer duration of stay in the ICU, more days on ventilator and higher total mortality during hospitalization. Multivariate logistic regression analysis identified antifungal use to be independently associated with total mortality during hospitalization. Antifungal use in patients with ICU-acquired RTI was associated with higher overall mortality as compared to those not receiving such agents.

Nationwide retrospective study of critically ill adults with sickle cell disease in France

Little is known about patients with sickle cell disease (SCD) who require intensive care unit (ICU) admission. The goals of this study were to assess outcomes in patients admitted to the ICU for acute complications of SCD and to identify factors associated with adverse outcomes. This multicenter retrospective study included consecutive adults with SCD admitted to one of 17 participating ICUs. An adverse outcome was defined as death or a need for life-sustaining therapies (non-invasive or invasive ventilation, vasoactive drugs, renal replacement therapy, and/or extracorporeal membrane oxygenation). Factors associated with adverse outcomes were identified by mixed multivariable logistic regression. We included 488 patients admitted in 2015–2017. The main reasons for ICU admission were acute chest syndrome (47.5%) and severely painful vaso-occlusive event (21.3%). Sixteen (3.3%) patients died in the ICU, mainly of multi-organ failure following a painful vaso-occlusive event or sepsis. An adverse outcome occurred in 81 (16.6%; 95% confidence interval [95% CI], 13.3%–19.9%) patients. Independent factors associated with adverse outcomes were low mean arterial blood pressure (adjusted odds ratio [aOR], 0.98; 95% CI 0.95–0.99; p = 0.027), faster respiratory rate (aOR, 1.09; 95% CI 1.05–1.14; p < 0.0001), higher haemoglobin level (aOR, 1.22; 95% CI 1.01–1.48; p = 0.038), impaired creatinine clearance at ICU admission (aOR, 0.98; 95% CI 0.97–0.98; p < 0.0001), and red blood cell exchange before ICU admission (aOR, 5.16; 95% CI 1.16–22.94; p = 0.031). Patients with SCD have a substantial risk of adverse outcomes if they require ICU admission. Early ICU admission should be encouraged in patients who develop abnormal physiological parameters.

Self-Managed Music-Guided Exercise Intervention Improved Upper and Lower Extremity Muscle Strength for ICU Survivors-A Pilot Randomized Controlled Study.

ObjectiveThe objective of this study was to evaluate effects of a self-managed music-guided exercise intervention on muscle strength among intensive care unit (ICU) survivors. Methods We used a two-arm randomized-controlled trial. Following ICU discharge, eligible participants were assigned to one of two groups: music group (n = 13) or active control group (n = 13). The music group was taught to self-manage upper and lower extremity exercise movements by listening to an individualized music-guided playlist twice daily for 5 days. The active control group was provided an exercise brochure and advised to perform the same exercises at the same intervals. Dynamometers were used to measure muscle strength. T-tests and Weighted GEE models were used for testing the intervention effect between groups. Results Twenty-six subjects were enrolled. The mean age was 62.8 (SD = 13.8), 53.8% were male, 65.4% were Caucasian, and the mean APACHE severity of illness score was 59 (SD = 23.4). Reasons for ICU admission were mainly cardiac and medical. The music group showed significant improvements in handgrip, plantar flexion, leg extension, elbow flexion, and shoulder adduction strengths on left and right sides. Additionally, left and right leg extensor and left plantar flexor strengths showed significant post-differences, and small to moderately large effect sizes, between the music group and control group. Conclusion These findings suggest that a music-guided exercise intervention has the potential to improve muscle strength in ICU survivors and prevent further post-ICU deterioration in ICU survivors. Future trials should build upon these preliminary findings.

Does the ICU Requirement Score allow the poisoned patient to be safely managed without admission to the intensive care unit? – a validation cohort study

Background The Intensive care unit (ICU) Requirement Score (IRS) has been defined as identifying poisoned patients on hospital admission who do not require ICU referral, in an effort to reduce health expenses. However, this score has been poorly validated. We aimed to evaluate the IRS in a large cohort of poisoned patients. Methods We performed a single-center retrospective cohort study. IRS was calculated using clinical parameters obtained on admission including age, systolic blood pressure, heart rate, Glasgow coma score, intoxication type, co-morbidities (i.e., arrhythmia, cirrhosis, and respiratory insufficiency), and the combination of the intoxication with another reason for ICU admission. We evaluated the ability of IRS < 6 determined on admission to predict the lack of need for ICU treatment, defined as the need for mechanical ventilation, vasopressors, and/or renal replacement therapy in the first 24 h post-admission and/or death during the hospital stay. This score was compared to the usual prognostic scores, i.e., SAPS II and III, SOFA score, and PSS. Results During the 10-year study period, 2,514 poisoned patients were admitted, 1,011 excluded as requiring ICU treatment on admission, and 1,503 included. Among these patients, 232 met the endpoint whereas only 23/510 patients with IRS < 6 (4.5%) presented the endpoint and one patient died. The area under the curve of the IRS ROC curve was 0.736 (95% confidence interval (CI), 0.702–0.770). The negative predictive value of IRS < 6 was 95% (95% CI, 93–97), sensitivity 89% (95% CI, 85–93), specificity 38% (95% CI, 36–41), and positive predictive value 21% (95% CI, 18–24). IRS performance was similar to those of the other tested scores, which are however not readily available on admission. Conclusion Our data demonstrate the excellent negative predictive value of the IRS, allowing the exclusion of ICU requirements for poisoned patients with IRS < 6. IRS usefulness should be confirmed based on a prospective multicenter cohort study before extensive routine use.

High mortality rate of obstetric critically ill women in Rwanda and its predictability

BackgroundReasons for admission to intensive care units (ICUs) for obstetric patients vary from one setting to another. Outcomes from ICU and prediction models are not well explored in Rwanda owing to lack of appropriate scores. This study aimed to assess reasons for admission and accuracy of prediction models for mortality of obstetric patients admitted to ICUs of two public tertiary hospitals in Rwanda.MethodsWe prospectively collected data from all obstetric patients admitted to the ICUs of the two public tertiary hospitals in Rwanda from March 2017 to February 2018 to identify reasons for admission, demographic and clinical characteristics, outcome including death and its predictability by both the Modified Early Obstetric Warning Score (MEOWS) and quick Sequential Organ Failure Assessment (qSOFA). We analysed the accuracy of mortality prediction models by MEOWS or qSOFA by using logistic regression adjusting for factors associated with mortality. Area under the Receiver Operating characteristic (AUROC) curves is used to show the predicting capacity for each individual tool.ResultsObstetric patients (n = 94) represented 12.8 % of all 747 ICU admissions which is 1.8 % of all 4.999 admitted women for pregnancy or labor. Sepsis (n = 30; 31.9 %) and obstetric haemorrhage (n = 24; 25.5 %) were the two commonest reasons for ICU admission. Overall ICU mortality for obstetric patients was 54.3 % (n = 51) with average length of stay of 6.6 ± 7.525 days. MEOWS score was an independent predictor of mortality (adjusted (a)OR 1.25; 95 % CI 1.07–1.46) and so was qSOFA score (aOR 2.81; 95 % CI 1.25–6.30) with an adjusted AUROC of 0.773 (95 % CI 0.67–0.88) and 0.764 (95 % CI 0.65–0.87), indicating fair accuracy for ICU mortality prediction in these settings of both MEOWS and qSOFA scores.ConclusionsSepsis and obstetric haemorrhage were the commonest reasons for obstetric admissions to ICU in Rwanda. MEOWS and qSOFA scores could accurately predict ICU mortality of obstetric patients in resource-limited settings, but larger studies are needed before a recommendation for their use in routine practice in similar settings.

Clinical outcomes in patients with malignant brain tumors admitted to the ICU.

e14034 Background: Primary brain malignancy is distinct from other oncologic diagnoses in its presentation and course. Recent treatment advances have modestly improved survival; yet, prognoses for afflicted patients remain grim, which often leads to non-oncology providers questioning the pertinence of aggressive critical care in this population. By relating patient and disease factors with mortality rates in malignant brain tumor (MBT) patients admitted for critical care, we seek to identify valuable prognostic factors and clarify the expected outcomes following intensive care unit (ICU) admission among these patients. Methods: A single-institution retrospective review was performed of 80 primary MBT patients admitted to neuro- or medical ICUs over a five-year period. The Electronic Health Record (EHR) was queried to identify MBT patients who had been admitted to the ICU. Patients undergoing planned surgical resection or with post-operative complications were excluded, as were patients with brain metastases. A matched control group of 80 solid tumor (ST) patients (excluding brain tumors) was included for comparison. Similar aged matched controls were randomly identified via EHR over the same time period to include non-brain, ST patients admitted to the ICU. Demographic, oncologic, and admission data were related to outcomes, which included complication rates (ICU mortality, six-month mortality) and change in Karnofsky Performance Status (KPS) score. Results: The average age was 55.9 (20-83) and 62.8 (27-89) years in the MBT and ST group, respectively (p = 0.10). ICU mortality was 15% and 21% (p = 0.411) and six-month mortality was 46% and 65% (p = 0.10) in the MBT and control groups, respectively. The most common reasons for ICU admission were seizures (36%) and septic shock (21%) among MBT patients, compared to hypoxic respiratory failure (43%) and septic shock (30%) among ST patients. The MBT group’s KPS score decreased by 23.6 ± 26.82 during their ICU admission, while the control group KPS decreased by 27.0 ± 28.3 (p = 0.87). Average length of ICU stay was 3.82 ± 4.4 days in the MBT group, compared to 2.95 ± 1.83 days in the control ST group (p = 0.29). Average length of hospital stay was 9.07 ± 9.0 days in the MBT group and 8.67 ± 7.76 days in the ST group (p = 0.92). Conclusions: No significant difference was observed in ICU or 6-month mortality when comparing primary MBT and ST patients. Change in KPS score across ICU admissions was similar among the two groups. Our data indicate that despite their guarded prognosis, MBT patients fare no worse than those with other solid tumor types at our institution in the critical care setting. These similarities in mortality and functional scores justify medical ICU admission in patients with primary brain malignancy, and should inform intensivist and oncologist admission patterns.

Use and outcome of empiric echinocandins in critically ill patients.

Echinocandins are recommended as a first-line empiric treatment for fungal infections of patients in an intensive care unit (ICU) with critical illness. The primary aim of the study was to compare outcomes among ICU patients treated with empiric anidulafungin (ANI), caspofungin (CASPO), or micafungin (MICA). A retrospective cohort study in a mixed adult ICU. Patient demographics, reason for ICU admission, ICU risk scores and organ support therapies were analyzed. Outcome parameters included ICU and hospital stay, 30-day mortality and 1-year mortality. Empiric echinocandin therapy was given to 367 patients (ANI; 73 patients, CASPO; 84 patients, and MICA; 210 patients) with a median duration of 3days in an ICU. Patient median age was 60.7years. As a first-line therapy, 52% of patients received fluconazole. Positive Candida cultures were found in the following samples: blood, 16 (4.4%); central line, 27 (7.4%); deep site, 92 (25.1%). Median ICU stay (ANI 6.4days, CASPO 5.3days, MICA 8.1days), hospital stay (ANI 33days, CASPO 30days, MICA 30days), 30-day mortality (ANI 27%, CASPO 32%, MICA 32%), and 1-year mortality (ANI 33%, CASPO 44%, MICA 45%) did not differ between the groups . The cost of antifungal therapy during the ICU period was similar in the three echinocandin groups (ANI; €1 872, CASPO; €1 799, and MICA; €1783). Our results show that ICU, hospital stay, and mortality (hospital, 30-day and 1-year) did not differ among patients with empiric anidulafungin, caspofungin, or micafungin treatment in a mixed adult ICU.