Requiring ICU Admission Research Articles

CO130 Dyspnea and Health-Related Quality of Life in Patients with Persistent Symptoms after at Least Six Months of Hospital Discharge Due to COVID-19

To evaluate dyspnea in patients with persistent symptoms after at least six months of hospital discharge due to COVID-19 and its correlation with the quality of life, fatigue, and functional status This cross-sectional study included 101 patients with persistent symptoms after at least six months of hospital discharge for COVID-19. A physician evaluated dyspnea using the Modified Medical Research Council (mMRC) scale questionnaire, the quality of life with the EQ-5D-5L, fatigue with an analog scale (0=no fatigue to 10=worst possible fatigue), and functional status with the Post-COVID-19 Functional Status scale (grade 0=no limitation to grade 4=severe limitation). We used Fisher’s exact test for categorical data and the Wilcoxon rank-sum test for continuous data to assess differences across groups. Spearman’s test was used for correlations. The significance level was 5%. Of the participants, 56.4 % (n=57) were women with a mean age of 57.7 (SD±16.3) years. The most reported symptoms were muscle weakness (61.4%, n=62), dyspnea (51.5%, n=52), muscle pain (49.5%, n=50), and fatigue 41 (40.6%, n=41). Seventy-two (71.3%) participants reported an increase in the mMRC dyspnea scale score, with no differences according to ICU requirements. Forty of the 81 (49.4%) participants with an mMRC grade 0 before COVID-19 reported a grade 3-4 during the medical visit. The EQ5D-5L index was 10% lower after COVID-19 (median difference: -0.01 points, interquartile range: -0.14 to -0.05), and those who required ICU admission had a more significant change in the index than those who did not (-0.12 vs -0.07, p=0.008). The mMRC grade reported during the medical visit was negatively correlated with the EQ5D-5L index (rho=-0.5836716, p<0.0001) and positively correlated with fatigue (rho=0.38,p =0.001) and functional status (rho=0.41,p <0.001). Dyspnea is prevalent among patients discharge for COVID-19 with persistent symptoms and may affect their quality of life and functional status.

Effect on in-hospital outcomes of patients with hepatocellular carcinoma on aspirin.

e16162 Background: Despite the use of new immunotherapies, hepatocellular carcinoma (HCC) has a poor survival rate. Through multiple molecular mechanisms, aspirin (ASA) has demonstrated a reduced incidence of HCC, however, the impact of long-term aspirin use on in-hospital outcomes has not been studied. Methods: We queried the National Inpatient Sample (NIS) database from 2016 to 2020 to identify patients with HCC. Patients were stratified into two groups, based on long-term aspirin use. Information was collected regarding patient demographics, Elixhauser comorbidities, interventions, etiology and decompensations of the liver disease. Outcomes studied included sepsis, shock, acute kidney injury, ICU admission, and in-hospital mortality. The association between long-term aspirin use and outcomes was studied using multivariate analysis. Results: 224,735 patients were included in the study. Of them, 18,835 (8.4%) patients were on long-term aspirin. The majority of the patients with ASA use were White (61.3%), men (78.2%), and aged &gt; 65 years old (68.8%). Patients in the ASA group had a higher incidence of NASH and decreased rates of hepatic decompensation than those not on ASA. Patients with aspirin use had lower incidence of sepsis (2.76% vs 3.54%), shock (4.86% vs 8.23%), AKI (30.9% vs 33.4%), ICU admission (3.88% vs 7.4%) and in-hospital mortality (5.18% vs 9.87%). After adjusting for confounding factors, ASA use was associated with a 30% lower risk of in-hospital mortality (aOR-0.70, 95% CI-0.60-0.82, p&lt;0.001). ASA users also had a 21% lower odds of developing shock (aOR-0.79, 95% CI-0.67-0.94, p-0.007) and 31% lower odds of requiring ICU admission (aOR-0.69, 95% CI-0.54-0.78, p&lt;0.001). No statistically significant difference was noted in the risk of sepsis and AKI between the two groups. Conclusions: Our study noted that patients on long-term aspirin use had better in-hospital outcomes such as mortality, shock and ICU admissions compared to non-aspirin users. These findings are of interest, and further randomized clinical trials confirming the benefits of aspirin in improving outcomes in HCC patients need to be conducted. [Table: see text]

CARDIOVASCULAR DISEASE AFTER PNEUMOCOCCAL PNEUMONIA

Objective: The purpose of this study was to assess the impact of arterial hypertension (AH) and dyslipidemia on the severity, cardiovascular events and death in patients hospitalized for pneumococcal community acquired pneumonia (CAP). Design and method: Retrospective, cohort, multicenter, epidemiologic study. All adult inpatients of 4 different centres in Portugal, with microbiological and clinical documented pneumococcal CAP were included. Demographic data, comorbidities, antibiotic therapy, hospital length of stay, need for ICU admission, invasive mechanical ventilation (IMV) and renal replacement therapy (RRT) were collected. All patients were monitored until death or 1-year of follow up. Risk factors for short- and long-term all-cause mortality, including cardiovascular events, were computed. Patients were divided into 3 groups: H) with isolated AH; HD) with both AH and dyslipidemia; Control) without AH or dyslipidemia. The significance level was defined as p &lt;0.05. Results: 797 patients were included in this study, 53.6% male, mean age 72.4±16.5 years. Comparing the 3 groups, females were prevalent in H and HD groups (52% and 54.3% vs 40.6% Control; p&lt;0.002). Mean age was higher in H and HD (78.2±12.6 and 78.4±10.7 years; vs Control 67.5±18.2 years, ANOVA p&lt;0.001). 18.8% patients required ICU admission, 6.7% IMV and 13.1% RRT. H required more IMV (7.5%, p = 0,5) and HD more RRT (16.6%, p = 0.2). The overall in-hospital mortality was 17.8%. During the follow up, H and HD groups were more readmitted to the emergency department due to cardiovascular events than Control group (11.7% and 13.4% vs. 6.5%, OR 1,91 p = 0.04 and OR 2.26 p = 0.016, respectively); also required more hospitalization for cardiovascular events than Control group (14.4% e 12.6% vs. 6.2%; OR 2.49, p = 0.002; and OR 1.99, p = 0.02, respectively). One-year all-cause mortality was higher in H group (39.2%; p = 0.026). Conclusions: Prevalence of arterial hypertension was 47.4%, higher than the national rate. H group resorted, with or without dyslipidemia, more often to the emergency department, requiring more hospitalization and with higher mortality rates, without difference in hospital mortality. It's crucial to control cardiovascular risk factors, providing greater cardiovascular protection to reduce the risk of long-term mortality.

COVID-19 Outcomes and Diabetes Mellitus: A Comprehensive Multicenter Prospective Cohort Study.

The link between type 2 diabetes (T2D) and the severe outcomes of COVID-19 has raised concerns about the optimal management of patients with T2D. This study aimed to investigate the clinical characteristics and outcomes of T2D patients hospitalized with COVID-19 and explore the potential associations between chronic T2D treatments and adverse outcomes. This was a multicenter prospective cohort study of T2D patients hospitalized with COVID-19 in Greece during the third wave of the pandemic (February-June 2021). Among the 354 T2D patients included in this study, 63 (18.6%) died during hospitalization, and 16.4% required ICU admission. The use of DPP4 inhibitors for the chronic management of T2D was associated with an increased risk of in-hospital death (adjusted odds ratio (adj. OR) 2.639, 95% confidence interval (CI) 1.148-6.068, p = 0.022), ICU admission (adj. OR = 2.524, 95% CI: 1.217-5.232, p = 0.013), and progression to ARDS (adj. OR = 2.507, 95% CI: 1.278-4.916, p = 0.007). Furthermore, the use of DPP4 inhibitors was significantly associated with an increased risk of thromboembolic events (adjusted OR of 2.249, 95% CI: 1.073-4.713, p = 0.032) during hospitalization. These findings highlight the importance of considering the potential impact of chronic T2D treatment regiments on COVID-19 and the need for further studies to elucidate the underlying mechanisms.

The association between the presence and burden of periodic discharges and outcome in septic patients: an observational prospective study

BackgroundSepsis-associated encephalopathy (SAE) is frequent in septic patients. Electroencephalography (EEG) is very sensitive to detect early epileptic abnormalities, such as seizures and periodic discharges (PDs), and to quantify their duration (the so-called burden). However, the prevalence of these EEG abnormalities in septic patients, as well as their effect on morbidity and mortality, are still unclear. The aims of this study were to assess whether the presence of electrographic abnormalities (i.e. the absence of reactivity, the presence and burden of seizures and PDs) was associated with functional outcome and mortality in septic patients and whether these abnormalities were associated with sepsis-associated encephalopathy (SAE).MethodsWe prospectively included septic patients, without known chronic or acute intracranial disease or pre-existing acute encephalopathy, requiring ICU admission in a tertiary academic centre. Continuous EEG monitoring was started within 72 h after inclusion and performed for up to 7 days. A comprehensive assessment of consciousness and delirium was performed twice daily by a trained neuropsychologist. Primary endpoints were unfavourable functional outcome (UO, defined as a Glasgow Outcome Scale-Extended—GOSE—score < 5), and mortality collected at hospital discharge and secondary endpoint was the association of PDs with SAE. Mann–Whitney, Fisher’s exact and χ2 tests were used to assess differences in variables between groups, as appropriate. Multivariable logistic regression analysis with in-hospital mortality, functional outcome, SAE or PDs as the dependent variables were performed.ResultsWe included 92 patients. No seizures were identified. Nearly 25% of patients had PDs. The presence of PDs and PDs burden was associated with UO in univariate (n = 15 [41%], p = 0.005 and p = 0.008, respectively) and, for PDs presence, also in multivariate analysis after correcting for disease severity (OR 3.82, IC 95% [1.27–11.49], p = 0.02). The PDs burden negatively correlated with GOSE (Spearman’s coefficient ρ = − 0.2, p = 0.047). The presence of PDs was also independently associated with SAE (OR 8.98 [1.11–72.8], p = 0.04). Reactivity was observed in the majority of patients and was associated with outcomes (p = 0.044 for both functional outcome and mortality).ConclusionOur findings suggest that PDs and PDs burden are associated with SAE and might affect outcome in septic patients.

Double barrelled uro-colostomy versus Ileal conduit for urinary diversion following pelvic exenteration: a single centre experience.

The ideal method for urinary diversion following total pelvic exenteration (TPE) remains unclear. This study compares the outcomes of double-barrelled uro-colostomy (DBUC) and ileal conduit (IC) in a single Australian centre. All consecutive patients who underwent pelvic exenteration with the formation of either a DBUC or an IC between 2008 and November 2022 were identified from the prospective database from the Royal Adelaide Hospital and St. Andrews Hospital. Demographic, operative characteristics, general perioperative, long-term urological and other relevant surgical complications were compared via univariate analyses. Of 135 patients undergoing exenteration, 39 patients were eligible for inclusion: 16 patients with a DBUC, and 23 patients with an IC. More patients in the DBUC group had previous radiotherapy (93.8% vs. 65.2%, P = 0.056) and flap pelvic reconstruction (93.7% vs. 45.5%, P = 0.002). The rate of ureteric stricture trended higher in the DBUC group (25.0% vs. 8.7%, P = 0.21), but in contrast, urine leak (6.3% vs. 8.7%, P>0.999), urosepsis (43.8% vs. 60.9%, P = 0.29), anastomotic leak (0.0% vs. 4.3%, P>0.999), and stomal complications requiring repair (6.3% vs. 13.0%, P = 0.63) trended lower. These differences were not statistically significant. Rates of grade III or greater complications were similar; however, no patients in the DBUC group died within 30-days or had grade IV complications requiring ICU admission compared with two deaths and one grade IV complication in the IC group. DBUC is a safe alternative to IC for urinary diversion following TPE, with potentially fewer complications. Quality of life and patient-reported outcomes are required.

Reversible Neuroimaging findings associated with Kratom use. (P12-5.021)

<h3>Objective:</h3> To report a case of reversible ischemic changes on MRI associated with chronic kratom use in a patient presenting with encephalopathy and seizures <h3>Background:</h3> Mitragyna speciosa, or kratom, is a psychoactive substance that targets multiple opioid receptors and has been an unregulated and under-reported substance of abuse. Its use has been reported to cause liver toxicity, respiratory depression, neuropsychiatric issues and even death. Its neurological side effects at this time are not well established. <h3>Design/Methods:</h3> We report a case of a 23-year-old male with a medical history significant for polysubstance abuse who presented for acute encephalopathy and seizure-like episode, requiring ICU admission and intubation for airway protection. <h3>Results:</h3> Patient initially presented with hypotension, leukocytosis, and lactic acidosis concerning sepsis. He was started on broad spectrum antibiotics for meningitis coverage and Keppra to prevent further seizures. Urine toxicology screen was negative. Once examined off sedation, the patient was noted to have right upper extremity weakness with babinski reflex on right concerning stroke therefore an MRI was obtained. It revealed small areas of confluent juxtacortical white matter abnormality high in the posterior frontal lobes bilaterally with some true diffusion restriction on the left suggestive of acute infarct. However, the appearance was unusual for a stroke. Further history from the family revealed that the patient uses Kratom on a daily basis for a number of years to help with anxiety. He had no further seizures and his mental status improved during the remainder of his hospitalization. Repeat MRI Brain 2 months after initial presentation showed resolution of the abnormalities. <h3>Conclusions:</h3> Kratom has been reported in the past to cause neurological issues like seizures or PRES. This case shows reversible ischemic neuroimaging findings of Kratom use in a patient with a stroke-like presentation. <b>Disclosure:</b> Dr. Pisati has nothing to disclose. Dr. Shah has nothing to disclose. Dr. Thaliath has nothing to disclose. Dr. Maryala has nothing to disclose. Dr. Allam has nothing to disclose.

Predictive value of coagulation variables and glycocalyx shedding in hospitalized COVID-19 patients – a prospective observational study

ABSTRACT Objectives Covid-19 disease causes an immense burden on the healthcare system. It has not yet been finally clarified which patients will suffer from a severe course and which will not. Coagulation disorders can be detected in many of these patients. The aim of the present study was therefore to identify variables of the coagulation system including standard and viscoelastometric tests as well as components of glycocalyx damage that predict admission to the intensive care unit. Methods Adult patients were included within 24 h of admission. Blood samples were analyzed at hospital admission and at ICU admission if applicable. We analyzed group differences and furthermore performed receiver operator characteristics (ROC). Results This study included 60 adult COVID-19 patients. During their hospital stay, 14 patients required ICU treatment. Comparing ICU and non-ICU patients at time of hospital admission, D-dimer (1450 µg/ml (675/2850) vs. 600 µg/ml (500/900); p = 0.0022; cut-off 1050 µg/ml, sensitivity 71%, specificity 89%) and IL-6 (47.6 pg/ml (24.9/85.4 l) vs. 16.1 pg/ml (5.5/34.4); p = 0.0003; cut-off 21.25 pg/ml, sensitivity 86%, specificity 65%) as well as c-reactive protein (92 mg/dl (66.8/131.5) vs. 43.5 mg/dl (26.8/83.3); p = 0.0029; cutoff 54.5 mg/dl, sensitivity 86%, specificity 65%) were higher in patients who required ICU admission. Thromboelastometric variables and markers of glycocalyx damage (heparan sulfate, hyaluronic acid, syndecan-1) at the time of hospital admission did not differ between groups. Conclusion General inflammatory variables continue to be the most robust predictors of a severe course of a COVID-19 infection. Viscoelastometric variables and markers of glycocalyx damage are significantly increased upon admission to the ICU without being predictors of ICU admission.

Anticoagulation strategy and safety in critically ill COVID-19 patients: a French retrospective multicentre study

BackgroundPatients with critical illness due to COVID-19 exhibit increased coagulability associated with a high risk of venous thrombo-embolism (VTE). Data on prophylactic anticoagulation for these patients are limited and conflicting. The purpose of this study was to evaluate whether intermediate-dose prophylactic anticoagulation in patients with COVID-19 requiring ICU admission was associated with better outcomes compared to standard-dose prophylactic anticoagulation.MethodsWe retrospectively included adults admitted with severe COVID-19 to any of 15 ICUs, in 2020 or 2021. We compared the groups given intermediate-dose vs. standard-dose prophylactic anticoagulation. The primary outcome was all-cause day-90 mortality. Secondary outcomes were VTE (pulmonary embolism or deep vein thrombosis), ICU stay length, and adverse effects of anticoagulation.ResultsOf 1174 included patients (mean age, 63 years), 399 received standard-dose and 775 intermediate-dose prophylactic anticoagulation. Of the 211 patients who died within 90 days, 86 (21%) received intermediate and 125 (16%) standard doses. After adjustment on early corticosteroid therapy and critical illness severity, there were no significant between-group differences in day-90 mortality (hazard ratio [HR], 0.73; 95%CI, 0.52–1.04; p = 0.09) or ICU stay length (HR, 0.93; 95%CI, 0.79–1.10; p = 0.38). Intermediate-dose anticoagulation was significantly associated with fewer VTE events (HR, 0.55; 95%CI, 0.38–0.80; p < 0.001). Bleeding events occurred in similar proportions of patients in the two groups (odds ratio, 0.86; 95%CI, 0.50–1.47; p = 0.57).ConclusionsMortality on day 90 did not differ between the groups given standard-dose and intermediate-dose prophylactic anticoagulation, despite a higher incidence of VTE in the standard-dose group.

A Three-Year Retrospective Study Assessing the Quality of the Course of Management of Infective Endocarditis in a Tertiary Hospital in Riyadh, Saudi Arabia.

Infective endocarditis (IE) is one of the most misdiagnosed diseases in Saudi Arabia because of the variable treatment regimen. This study aims to assess the quality of the management of infective endocarditis in a tertiary care teaching hospital. A single-center retrospective cohort study was conducted, based on electronic medical records extracted from the BestCare electronic medical record system, of all patients who presented with infective endocarditis as a final diagnosis from 2016 to 2019. Out of a total of 99 patients diagnosed with infective endocarditis, 75% of our patients had blood cultures ordered before initiating empirical antibiotic therapy. Positive blood cultures were reported in 60% of patients. Staphylococcus aureus was the most common organism, identified in 18% of our patients, followed by Streptococcus viridans at 5%. Empirical antibiotics were initiated in 81% of patients. Proper antibiotic coverage was initiated within a week for 53% of the patients, and 14% had proper antibiotic coverage within two weeks. On echocardiography, 62% of the patients had vegetation that was present in a single valve. The mitral valve had the highest incidence of vegetation (24%), followed by the aortic valve (21%). Follow-up echocardiography was done in 52% of patients. It showed regressed vegetation in 43% of patients, while only 9% of patients had no vegetation regression. Valve repair was done in 25% of patients. Out of 99 patients, 47 required ICU admission. The mortality rate was 18%. Overall management of infective endocarditis in the study hospital was appropriate and highly compliant with guidelines, with a few areas that could be improved further.

Twenty-Seven-Year Retrospective Review of Hemoptysis from Systemic Collaterals Following Pulmonary Arteriovenous Malformation Embolization

To determine the prevalence of hemoptysis secondary to post-embolization systemic collaterals and review the recurrence rate and treatment outcomes. The records of 930 patients with PAVM (801 with known or possible HHT), from a single HHT center between July 2, 1996 and July 22, 2021, were searched for a single lifetime episode of hemoptysis secondary to post-embolization systemic collaterals. Embolization was performed with permanent particles or gelatin slurry. Clinical features and treatment outcomes of identified patients were reviewed. Twenty-eight embolization procedures have been performed in 9 patients with post-PAVM embolization systemic artery collateral reperfusion. This included 8 patients with known HHT. Permanent particles were used in 5 cases and gelatine slurry was used in 19 cases. Due to the recurrence of hemoptysis, four patients required four embolizations each, two patients required three embolizations and two patients required two embolizations. Chronic unresolving hemoptysis was the presentation in 5 patients and massive hemoptysis requiring ICU admission in 4. The lifetime prevalence and incidence of hemoptysis secondary to systemic artery reperfusion in HHT patients was estimated to be 1.0% and 0.05%, respectively. Bronchial artery origin was most common (8 patients). In the first patient treated at this center, a major adverse event resulting in myocardial infarct and stroke occurred with the use of 300-500-micron permanent particles. This was presumed to be due to left-to-right shunting and subsequent systemic embolization. Subsequent patients were treated with gelatin sponge slurry without adverse events. This patient ultimately expired due to large volume hemoptysis, in the setting of bilateral diffuse PAVMs. A second patient, with history of childhood bronchial artery coil embolization, expired from large volume hemoptysis while awaiting lobectomy. In two cases, patients underwent surgery, including one lobectomy and one pneumonectomy, for recurrent hemoptysis (requiring at least five hospital admissions). The remaining five patients achieved prolonged resolution of hemoptysis with endovascular treatment alone. Lifetime prevalence of hemoptysis secondary to PAVM post-embolization systemic collaterals is rare, but recurrence is high. In this limited series, embolization with gelatin sponge slurry appeared safe, although surgical resection may ultimately be required in refractory and multifocal disease.

Single-center study on SARS-CoV-2 infection in patients affected by CML: Vaccination status and bosutinib therapy as possible protective factors for hospitalization.

COVID-19 pandemic had a considerable impact among haematological patients. On the other hand, the effect of this disease on patients (pts) affected by Chronic Myeloid Leukemia (CML) is not clearly defined. The primary objective of this study was to evaluate mortality-hospitalization rates and possible protective factors for hospitalization in CML pts affected by COVID. We collected data from CML patients followed at our institution whotested positive for SARS-CoV-2 infection. The following variables were assessed: demographical data, type of TKI therapy, vaccination status, presence of cardiovascular disease (CVD), period of infection, COVID-19 presenting symptoms, severity and mortality. Data were collected retrospectively and then analysed in univariate and multivariate analysis. Out of a total of 325 CML pts treated at our institution, we recorded 72 SARS-CoV-2pts (22%) who tested positive with a SARS-CoV-2 PCR assay. Twenty two were infected in 2020 (30%), 16 patients in 2021 (22%) and 34 in 2022 (46%); with a hospitalization rate of 27%, 25% and 3% respectively. Of the 72 confirmed infections, 13 pts (18%; (CI) 10-28) were asymptomatic and 48 (66%; CI: 55-76) had mild symptoms. A total of 11 pts were admitted to hospital and 3 of these required ICU admission. No deaths were recorded. The probability of hospitalization was significantly reduced if patients were vaccinated (odds ratio OR 0.037 with CI: 0-0.33 p 0.002) or treated with Bosutinib (OR 0.06 with CI: 0-0.5 p 0.008). In the present study, no significant increase in mortality was noted among patients with CML as compared to the general population inItaly. Vaccination and treatment with bosutinib were identified as baseline characteristics that were associated with a decreased risk of hospitalitazion resulting from COVID-19 infection.

The adjusted impact of different severities of acute exacerbations and medications on the risk of developing dementia in COPD patients

BackgroundAlthough a relationship between chronic obstructive pulmonary disease (COPD) and dementia has been reported, the initial severity upon emergency department (ED) visits and the medications used have not been well evaluated as risk factors for increased dementia occurrence. We aimed to analyze the risks of dementia development over 5 years among patients with COPD compared to matched controls (primary) and the impact of different severities of acute exacerbations (AEs) of COPD and medications on the risk of dementia development among COPD patients (secondary).MethodThis study used the Taiwanese government deidentified health care database. We enrolled patients during the 10-year study period (January 1, 2000, to December 31, 2010), and each patient was followed up for 5 years. Once these patients received a diagnosis of dementia or died, they were no longer followed up. The study group included 51,318 patients who were diagnosed with COPD and 51,318 matched (in terms of age, sex, and the number of hospital visits) non-COPD patients from the remaining patients as the control group. Each patient was followed up for 5 years to analyze the risk of dementia with Cox regression analysis. Data on medications (antibiotics, bronchodilators, corticosteroids) and severity at the initial ED visit (ED treatment only, hospital admission, or ICU admission) were collected for both groups, as well as demographics and baseline comorbidities, which were considered confounding factors.ResultsIn the study and control groups, 1,025 (2.0%) and 423 (0.8%) patients suffered from dementia, respectively. The unadjusted HR for dementia was 2.51 (95% CI: 2.24–2.81) in the study group. Bronchodilator treatment was associated with the HRs, especially among those who received long-term (> 1 month) treatment (HR = 2.10, 95% CI: 1.91–2.45). Furthermore, among 3,451 AE of COPD patients who initially visited the ED, patients who required ICU admission (n = 164, 4.7%) had a higher risk of dementia occurrence (HR = 11.05, 95% CI: 7.77–15.71).ConclusionBronchodilator administration might be associated with a decreased risk of dementia development. More importantly, patients who suffered AEs of COPD and initially visited the ED and required ICU admission had a higher risk of developing dementia.

SURGICAL RIB FRACTURE FIXATION IN THE NORTH OF SCOTLAND: EARLY OPERATIVE INTERVENTION IMPROVES OUTCOMES

This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or non-operative management at our center over a six-year time period.Retrospective analysis was performed to identify all patients with complex rib fractures at our center from May 2016 to September 2022. Outcome measures included mechanical ventilation, tracheostomy, pneumonia, and mortality at one year.388 patients with complex rib fractures were identified. 37 (10%) patients fulfilled criteria for surgical management and underwent rib fracture fixation; 351 patients were managed non-operatively with anaesthetic block or analgesia alone. The fixation group had a significantly higher proportion of patients with flail chest (30 (81%) vs 94 (27%), p&lt;0.001) and were significantly more likely to require ICU admission (30 (81%) vs. 16 (5%), p&lt;0.001) than the non-operative group. At one year follow-up, no significant differences were seen for mortality between these groups (1 (3%) vs. 27 (7%), p=0.276).Of the surgical management group, those that underwent fixation &lt;72 hours post injury were significantly less likely to develop pneumonia than those who were delayed &gt;72 hours (2 (18%) vs 15 (58%), p=0.038), with downward trends noted for ICU length of stay (6 vs 10 days, p=0.140) and duration of mechanical ventilation (5 vs 8 days, p=0.177); no significant differences were seen for tracheostomy (3 vs. 5, p=0.588) or mortality (0 vs 1, p=0.856).Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Early surgical fixation led to reduced rates of pneumonia and may improve other outcome measures.

Cecal gangrene – Unusual complication of manual bowel decompression

We present a case of a 31-year-old female who presented with complaints of obstipation. Imaging features were suggestive of small bowel obstruction with transition point at distal ileum. On emergency laparotomy, the patient was found to have fecal impaction, for which manual bowel decompression (milking) was done. The patient developed hypotension intraoperatively requiring ICU admission for post-operative management. Post-operative CT demonstrated features of hypotension with gangrenous changes in the cecal wall. Re-exploration surgery demonstrated features of cecal gangrene consistent with imaging findings.

Critically ill severe hypothyroidism: a retrospective multicenter cohort study

BackgroundSevere hypothyroidism (SH) is a rare but life-threatening endocrine emergency. Only a few data are available on its management and outcomes of the most severe forms requiring ICU admission. We aimed to describe the clinical manifestations, management, and in-ICU and 6-month survival rates of these patients.MethodsWe conducted a retrospective, multicenter study over 18 years in 32 French ICUs. The local medical records of patients from each participating ICU were screened using the International Classification of Disease 10th revision. Inclusion criteria were the presence of biological hypothyroidism associated with at least one cardinal sign among alteration of consciousness, hypothermia and circulatory failure, and at least one SH-related organ failure.ResultsEighty-two patients were included in the study. Thyroiditis and thyroidectomy represented the main SH etiologies (29% and 19%, respectively), while hypothyroidism was unknown in 44 patients (54%) before ICU admission. The most frequent SH triggers were levothyroxine discontinuation (28%), sepsis (15%), and amiodarone-related hypothyroidism (11%). Clinical presentations included hypothermia (66%), hemodynamic failure (57%), and coma (52%). In-ICU and 6-month mortality rates were 26% and 39%, respectively. Multivariable analyses retained age > 70 years [odds ratio OR 6.01 (1.75–24.1)] Sequential Organ-Failure Assessment score cardiovascular component ≥ 2 [OR 11.1 (2.47–84.2)] and ventilation component ≥ 2 [OR 4.52 (1.27–18.6)] as being independently associated with in-ICU mortality.ConclusionsSH is a rare life-threatening emergency with various clinical presentations. Hemodynamic and respiratory failures are strongly associated with worse outcomes. The very high mortality prompts early diagnosis and rapid levothyroxine administration with close cardiac and hemodynamic monitoring.

Characteristics, Management, and Outcomes of Community-Acquired Pneumonia due to Respiratory Syncytial Virus: A Retrospective Study.

Respiratory syncytial virus (RSV), a well-known cause of bronchiolitis in children, can cause community-acquired pneumonia (CAP) in adults, but this condition is not well studied. Hence, we described the characteristics and outcomes of patients hospitalized for CAP due to RSV. This was a retrospective study of patients admitted to a tertiary-care hospital between 2016 and 2019 with CAP due to RSV diagnosed by a respiratory multiplex PCR within 48 hours of admission. We compared patients who required ICU admission to those who did not. Eighty adult patients were hospitalized with CAP due to RSV (median age 69.0 years, hypertension 65.0%, diabetes 58.8%, chronic respiratory disease 52.5%, and immunosuppression 17.5%); 19 (23.8%) patients required ICU admission. The median pneumonia severity index score was 120.5 (140.0 for ICU and 102.0 for non-ICU patients; p = 0.09). Bacterial coinfection was rare (10.0%). Patients who required ICU admission had more hypotension (systolic blood pressure < 90 mmHg) and a higher prevalence of bilateral infiltrates on chest X-ray (CXR) (89.5% versus 32.7%; p < 0.001). Systemic corticosteroids were used in 57.3% of patients (median initial dose was 40 mg of prednisone equivalent) with ICU patients receiving a higher dose compared to non-ICU patients (p = 0.02). Most (68.4%) ICU patients received mechanical ventilation (median duration of 4 days). The overall hospital mortality was 8.8% (higher for ICU patients: 31.6% versus 1.6%, p < 0.001). Most patients with CAP due to RSV were elderly and had significant comorbidities. ICU admission was required in almost one in four patients and was associated with higher mortality.

Biomarker Profiles Associated with COVID-19 Severity and Mortality.

The aim of this study was to analyze biomarkers that might predict the severity and progression of the SARS-CoV-2 infection, both in the acute phase and after recovery. Unvaccinated patients infected with the original strain of COVID-19 requiring ward (Group 1, n = 48) or ICU (Group 2, n = 41) admission were included. At the time of admission (visit 1), a clinical history was acquired, and blood samples were obtained. One and six months after discharge from the hospital (visits 2 and 3, respectively), a clinical history, lung function tests, and blood samples were carried out. At visit 2, patients also underwent a chest CT scan. Different cytokines (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12p70, IL-13, IL-17A, G-CSF, GM-CSF, IFN-ɣ, MCP-1, MIP-1β, and TNF-α) and lung fibrosis biomarkers (YKL-40 and KL-6) were measured in blood samples obtained at visits 1, 2, and 3. At visit 1, IL-4, IL-5, and IL-6 levels were higher in Group 2 (p = 0.039, 0.011, and 0.045, respectively), and IL-17 and IL-8 levels were higher in Group 1 (p = 0.026 and 0.001, respectively). The number of patients in Groups 1 and 2 who died during hospitalization was 8 and 11, respectively. YKL-40 and KL-6 levels were higher in patients who died. Serum YKL-40 and KL-6 levels determined at visit 2 correlated negatively with FVC (p = 0.022 and p = 0.024, respectively) and FEV1 (p = 0.012 and p = 0.032, respectively) measured at visit 3. KL-6 levels also correlated negatively with the diffusing capacity of the lungs for carbon monoxide (DLCO, p = 0.001). Patients who required ICU admission had higher levels of Th2 cytokines, while patients admitted to the ward showed an innate immune response activation, with IL-8 release and Th1/Th17 lymphocyte contribution. Increased levels of YKL-40 and KL-6 were associated with mortality in COVID-19 patients.

EVALUATING THE MATERNAL OUTCOME IN OBSTETRIC ICU A STUDY FROM A TERITIARY CARE HOSPITAL IN SOUTH INDIA

Background : Critically ill obstetric patients pose challenges to the intensive care unit team due to their altered physiology as well as due the presence of the foetus and safety of both the mother and the foetus is of most important. A better knowledge of the spectrum, characteristics and outcomes of the diseases involving this group of patients is the first step towards achieving prevention and the current study is done to supplement the present knowledge on obstetric emergencies requiring ICU care. Aims and Objectives :The objective is to study the profile of cases admitted to obstetric ICU and to evaluate maternal outcome and prognosis. Materials and Methods :This is observational study was conducted at Andhra Medical College ,visakhapatnam a teritiary care hospital from January 2022 to June 2022 . 1. All antenatal women irrespective of the period of gestation and postnatal women within 42 days of delivery requiring ICU admission for obstetric, non-obstetric reasons,irrespective of age, parity, mode of delivery, and co-morbid conditions were included . 2. Results were subjected to statistical analysis and conclusions drawn. Results : During the study period of 6 months, a total number of 82 obstetric patients were admitted to ICU. Specific interventions that had been undertaken at the ICU (such as the use of intubation, mechanical ventilation, and intensive monitoring )were recorded. The complications that were encountered at the ICU, such as disseminated intravascular coagulation (DIC) and multiorgan failure, were recorded. Majority were of obstetric reasons (n=58, 70.7%).Non-obstetric reasons (n=24, 29.3%) 28 maternal deaths occurred during the study period.Most common cause of death in our study was MODS followed by complications of hypertensive disorders of pregnancy. Discussion : Present centre being a tertiary care hospital majority of the women had severe complications and many were referred after a significant amount of delay .This stresses the idea that, in cases involving obstetric patients, there could not be much time for transfer to an intensive care unit and that things could swiftly deteriorate. Lack of antenatal care, poor socio economic background, delay in referral from the peripheral health centres predicted poor outcomes. Conclusion : The findings of the present study reinforce the statement by WHO that There is a story behind every maternal death or life-threatening complication. Understanding the lessons to be learned can help to avoid such outcomes. A multidisciplinary team approach is required in ICU. All residents of obstetrics and gynaecology should have short mandatory training phase in critical care.

Occurrence, Risk Factors, and Outcomes of Pulmonary Barotrauma in Critically Ill COVID-19 Patients: A Retrospective Cohort Study.

Pulmonary barotrauma has been frequently observed in patients with COVID-19 who present with acute hypoxemic respiratory failure. This study evaluated the prevalence, risk factors, and outcomes of barotrauma in patients with COVID-19 requiring ICU admission. This retrospective cohort study included patients with confirmed COVID-19 who were admitted to an adult ICU between March and December 2020. We compared patients who had barotrauma with those who did not. A multivariable logistic regression analysis was performed to determine the predictors of barotrauma and hospital mortality. Of 481 patients in the study cohort, 49 (10.2%, 95% confidence interval: 7.6-13.2%) developed barotrauma on a median of 4 days after ICU admission. Barotrauma manifested as pneumothorax (N = 21), pneumomediastinum (N = 25), and subcutaneous emphysema (N = 25) with frequent overlap. Chronic comorbidities and inflammatory markers were similar in both patient groups. Barotrauma occurred in 4/132 patients (3.0%) who received noninvasive ventilation without intubation, and in 43/280 patients (15.4%) who received invasive mechanical ventilation. Invasive mechanical ventilation was the only risk factor for barotrauma (odds ratio: 14.558, 95% confidence interval: 1.833-115.601). Patients with barotrauma had higher hospital mortality (69.4% versus 37.0%; p < 0.0001) and longer duration of mechanical ventilation and ICU stay. Barotrauma was an independent predictor of hospital mortality (odds ratio: 2.784, 95% confidence interval: 1.310-5.918). s. Barotrauma was common in critical COVID-19, with invasive mechanical ventilation being the most prominent risk factor. Barotrauma was associated with poorer clinical outcomes and was an independent predictor of hospital mortality.