Time Of Intensive Care Unit Admission Research Articles

Lower Apache II Score and Exchange Transfusions Predict Better Outcomes in the Intensive Care Unit for Patients with Sickle Cell Disease

Sickle cell disease (SCD) is an inherited red blood disorder that leads to acute episodes of worsening hemolysis and vaso-occlusion. The clinical course of these exacerbations can be unpredictable and some patients have rapid clinical deterioration requiring care in the intensive care unit (ICU). The utility of the Acute Physiology and Chronic Health Evaluation (APACHE II) score to predict ICU outcomes is unclear. We investigated the etiologies and outcomes in SCD patients requiring admission to the ICU at our institution, and the ability of the APACHE II score to predict length of stay (LOS) and mortality. Subjects were identified from a prospective registry of 439 SCD patients and baseline clinical data was obtained at the time of enrolment into the registry. The APACHE II score was calculated using the worst physiologic values measured within 24 hours of admission to the ICU. Linear and categorical variables were compared by the Kruskall-Wallis and chi-square test, respectively, and median (interquartile [IQR]) values are provided. Between 1/2008 and 2/2020, 134 (31%) SCD patients required 338 ICU admissions over a median follow up time of 8.8 years after enrollment into the registry (IQR, 6.5 - 9.4 years). SCD patients that required an ICU admission had higher median systolic blood pressure (122 vs. 117 mmHg, P=0.004) and white blood cell count (10.3 vs. 9.5 x 103/uL, P=0.09) and lower median estimated glomerular filtration rate (123 vs. 134 mL/min/1.73m2, P=0.02) at entry into the registry compared to those that did not require admission to the ICU during the follow-up period. After adjusting for age, sex, hydroxyurea use and SCD genotype, a higher baseline systolic blood pressure was independently associated with risk of ICU admission by logistic regression analysis (OR 9.3 for each natural log increase in blood pressure, 95%CI 1.3-67.5; P=0.03). The median age at the time of ICU admission was 40 years (IQR, 27 - 50 years); 53% of the patients were female, 78% had Hb SS/Sβ0-thalassemia genotype, and 48% were on hydroxyurea therapy. Acute chest syndrome was the most common cause of admission to the ICU, representing 57% of the cases (Figure 1A). While in the ICU, 19.2% required ventilation support (8% mechanical ventilation, 11.2% bilevel positive airway pressure) and 6.2% required vasopressor support. Acute kidney injury, as defined by the KDIGO guidelines, was observed in 33.7% of ICU admissions (Figure 1B) and 4.1% required acute initiation of renal replacement therapy. Acute thrombosis occurred in 5.1% of ICU SCD patients (1.5% deep vein thrombosis, 3.6% pulmonary emboli). While in the ICU, the median LOS was 1.1 days (IQR, 0.7 - 2.0 days) and 10 deaths occurred (3% of ICU admissions). The median APACHE II score was 15 (IQR, 9-21) and the score was directly associated with ICU LOS (r=0.41, P<0.0001) (Figure 1C) and a higher risk for death (OR 2.2 for each age-adjusted 5-point increment, 95%CI: 1.5-3.4; P=0.0002) (Figure 1D). An exchange transfusion was performed in 126 (37.3%) of the ICU admissions. Mortality was 0.8% in patients not receiving an exchange transfusion versus 4.3% in those not receiving exchange (P=0.07). After adjusting for age and APACHE II score, the odds ratio of death in patients receiving an exchange transfusion was 0.12 (95%CI 0.01 - 1.26; P=0.08). In conclusion, we demonstrate that approximately one-third of SCD patients require ICU care and that acute chest syndrome is the most common reason. Despite frequent requirement for vasopressor, ventilation or renal support, the mortality rate was low at 3%. This rate is substantially lower than the 8 - 19% mortality rate observed in general ICU admissions. The APACHE II score, a tool that predicts ICU outcomes, was predictive of LOS and risk of death in our SCD cohort. Furthermore, exchange transfusion was associated with a trend of lower mortality. Future studies on clinical predictors of ICU admissions and outcomes could help clinicians anticipate sickle cell complications and mortality and encourage early intervention such as the use of exchange transfusion. Figure Disclosures Gordeuk: Ironwood: Research Funding; Imara: Research Funding; CSL Behring: Consultancy, Research Funding; Global Blood Therapeutics: Consultancy, Research Funding; Novartis: Consultancy. Saraf:Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees, Other: Advisory Boards, Speakers Bureau; Pfizer, Global Blood Therapeutics, Novartis: Research Funding; Novartis, Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees.

Impact of early ICU admission for critically ill cancer patients: Post-hoc analysis of a prospective multicenter multinational dataset.

Early intensive care unit (ICU) admission, in Critically Ill Cancer Patients (CICP), is believed to have contributed to the prognostic improvement of critically ill cancer patients. The primary objective of this study was to assess the association between early ICU admission and hospital mortality in CICP. Retrospective analysis of a prospective multicenter dataset. Early admission was defined as admission in the ICU<24h of hospital admission. We assessed the association between early ICU admission and hospital mortality in CICP via survival analysis and propensity score matching. Of the 1011patients in our cohort, 1005 had data available regarding ICU admission timing and were included. Overall, early ICU admission occurred in 455 patients (45.3%). Crude hospital mortality in patients with early and delayed ICU admission was 33.6% (n=153) vs. 43.1% (n=237), respectively (P=0.02). After adjustment for confounders, early compared to late ICU admission was not associated with hospital mortality (HR 0.92; 95%CI 0.76-1.11). After propensity score matching, hospital mortality did not differ between patients with early (35.2%) and late (40.6%) ICU admission (P=0.13). In the matched cohort, early ICU admission was not associated with mortality after adjustment on SOFA score (HR 0.89; 95%CI 0.71-1.12). Similar results were obtained after adjustment for center effect. In this cohort, early ICU admission was not associated with a better outcome after adjustment for confounder and center effect. The uncertainty with regard to the beneficial effect of early ICU on hospital mortality suggests the need for an interventional study.

C-reactive protein and ferritin levels and length of intensive care unit stay in patients with B-cell lymphomas treated with axicabtagene ciloleucel

Objective/BackgroundChimeric antigen receptor (CAR) T-cell is an effective therapy in relapsed/refractory large B-cell lymphomas that, due to its unique toxicities, often requires escalation of care to the intensive care unit (ICU) setting. C-reactive protein (CRP) and ferritin are serum inflammatory markers associated with onset and persistence of CAR T-cell-related toxicity. MethodsWe retrospectively analyzed 34 patients treated with axicabtagene ciloleucel (axi-cel) who were divided into two groups: patients requiring admission to the ICU during initial hospitalization (n = 13, 38%) and those who did not (n = 21, 62%). Primary objective was to examine possible relationships between serum ferritin and/or CRP levels with the need for, and length of, ICU stay between these groups. ResultsAll 13 patients admitted to the ICU developed cytokine release syndrome (CRS) and 11 of them also developed neurotoxicity (NT). Of the 21 patients in the non-ICU group, 18 developed CRS and 5 patients developed NT. Grade of CRS and NT were higher in ICU versus non-ICU patients (p = .03 and .001, respectively). There was no correlation between CRP levels at time of ICU admission and length of ICU stay (correlation of 0.41, p = .17). Yet, there was an association between serum ferritin levels and length of ICU stay (R2 = 0.73) which did not reach statistical significance (correlation of 0.21, p = .49). ConclusionNotwithstanding the limitations of the small sample size, our study suggests that an elevated ferritin level at the time of escalation of medical care may be possibly indicative of anticipated prolonged ICU hospitalization in patients treated with axi-cel. A large multicenter study is certainly needed to confirm this observation.

Phase Angle and Frailty Are Important Prognostic Factors in Critically Ill Medical Patients: A Prospective Cohort Study.

ObjectivesTo investigate whether phase angle (PhA) measured by bioelectrical impedance analysis (BIA) and frailty are associated with the outcomes of critical illnesses.DesignA single-center prospective cohort study.SettingMedical intensive care unit (ICU) in Seoul National University Hospital, Seoul, Republic of Korea.Participants97 patients who were admitted to the medical ICU.MeasurementsOn admission, PhA was measured by BIA, and frailty was assessed by the Korean Modified Barthel Index (KMBI) scoring system. Patients were classified according to PhA and KMBI scores, and their impact on the outcomes of critical illnesses was evaluated.ResultsThe patients’ mean age was 62.4 ± 16.4 years, and 56 of the patients (57.7%) were men. Having a high PhA above 3.5 at the time of ICU admission was associated with lower in-hospital mortality (adjusted OR 0.42, p =.042), and a shorter duration of ICU stay (5.6 days vs. 9.8 days, p =.016) compared to those with a low PhA. Other indices measured by BIA were not significantly associated with outcomes of critical illnesses. Frailty (KMBI > 60) was associated with more mechanical ventilation days (2.3 days vs. 7.1 days; p =.018).ConclusionBoth PhA and frailty are important prognostic factors predicting the outcomes of critical illnesses. Low PhA scores were associated with increased mortality and a longer duration of ICU stay, and frailty was associated with more mechanical ventilation days.

Acute Kidney Injury in Critically-ill Patients With COVID-19: A Single-center Experience of 206 Consecutive Patients.

Knowledge about the epidemiology, diagnosis, and management of coronavirus disease 2019 (COVID-19) is rapidly evolving. More evidence is accumulating that COVID-19 is a systemic disease with more extra-pulmonary manifestations than initially thought.1–3 We describe here the incidence, predictors, and prognosis of acute kidney injury (AKI) in critically-ill patients with COVID-19. Data were collected prospectively for all patients with severe COVID-19 admitted to all intensive care units (ICUs) at the Massachusetts General Hospital, Boston, MA, USA between March 13th and April 22nd, 2020. COVID-19 infection was confirmed in all patients via reverse-transcriptase-polymerase-chain-reaction testing. AKI with or without the need for renal replacement therapy (RRT) was defined using the Kidney Disease: Improving Global Outcomes criteria.4 In our institution, the decision to start RRT is made by the nephrology team together with the critical care team. Univariate and multivariable analyses were performed to identify independent predictors for AKI and the need for RRT. A total of 206 consecutive patients were included. The median [interquartile ranges (IQR)] age was 60 years (47, 71), and 134 patients (65.1%) were males; 89 patients (43.2%) had diabetes mellitus, 27 (13.1%) had a history of chronic kidney disease, and 7 (3.4%) were dialysis-dependent before hospital admission. The median (IQR) Sequential Organ Failure Assessment score at the time of ICU admission was 5 (3, 7.5), and 87% of patients were intubated and mechanically ventilated. Of 206 patients, 148 (71.8%) developed AKI. Table S1 in the Supplementary Appendix, https://links.lww.com/SLA/C440 shows the univariate analyses comparing the demographics, comorbidities, and clinical presentation of AKI and non-AKI patients. In the AKI patient population, 62 (41.9%) had significant hyperkalemia (K+ > 5.5 mmol/L), 37 (25.0%) had oliguria/anuria (urine output < 100 mL/d), and 103 (69.6%) developed metabolic acidosis (pH < 7.30). The mean highest creatinine and blood urea nitrogen of patients that developed AKI were 3.80 mg/dL and 77 mg/dL, respectively. Forty-three percent of patients were diagnosed with AKI on hospital admission, whereas 89.2% of the patients developed AKI by hospital day 6 (Fig. 1 in the Supplementary Appendix, https://links.lww.com/SLA/C443). Almost half of the patients (70 patients, 47.3%) with AKI had a severe stage 3 disease, and of those, 46 (65.7%) progressed to require RRT; 24 patients were started and maintained on accelerated veno-venous hemofiltration or continuous veno-venous hemofiltration, 4 patients on hemodialysis, and 18 patients were started on accelerated veno-venous hemofiltration/continuous veno-venous hemofiltration but later transitioned to hemodialysis. The median (IQR) duration of RRT in our patient population was 14.5 (3, 22) days; the median (IQR) duration of RRT in the surviving cohort of patients was 18 (15, 32) days. At the time of this report, out of the 46 patients requiring RRT, 27 (58.7%) are alive; 7 are still in the hospital (5 have recovered renal function and 2 remain RRT dependent) and 20 patients have been discharged (15 have recovered renal function and 5 patients were discharged on RRT). Clotting in the dialysis circuit was encountered in 33 (73.3%) patients undergoing RRT. On multivariable analyses, older age, male gender, and higher body mass index (BMI) were identified as independent predictors for the development of AKI (Table S2 in the Supplementary Appendix, https://links.lww.com/SLA/C441). Similarly, male sex, higher BMI, and hypertension were identified as independent predictors of the need for RRT among AKI patients (Table S3 in the Supplementary Appendix, https://links.lww.com/SLA/C442). To date, both ICU and hospital mortality are significantly higher in the AKI vs. non-AKI patients (27.7% vs 5.2%, P-value < 0.001 and 33.1% vs 8.6%, P-value < 0.001, respectively). At the time of this report, 8 (3.9%) patients are still hospitalized. In this series of critically-ill COVID-19 patients, we report an extremely high incidence of AKI; almost a third of the patients required RRT. This might be secondary to kidney hypoperfusion or medication adverse effects; however, COVID-19 related pathophysiologic mechanisms, including cytokine storm and cell-mediated renal injury, could have played a role and thus warrant further investigation.5,6 Male gender and higher BMI were identified as independent predictors for the development of AKI and the requirement of RRT among critically-ill COVID-19 patients. The rate of AKI reported herein is significantly higher than the one reported by Hirsch et al (71.8% vs 36.6%).7 In their study the identified risk factors for AKI included older age, diabetes mellitus, cardiovascular disease, black race, hypertension, ventilation requirement, and administration of vasopressors.7 The hospital mortality rate of AKI patients was nearly 4 times that of non-AKI patients. Front line clinicians should be aware of these renal morbidities and should monitor closely patients’ renal function with prompt early intervention when possible.

ICU admission body composition: skeletal muscle, bone, and fat effects on mortality and disability at hospital discharge\u2014a prospective, cohort study

BackgroundReduced body weight at the time of intensive care unit (ICU) admission is associated with worse survival, and a paradoxical benefit of obesity has been suggested in critical illness. However, no research has addressed the survival effects of disaggregated body constituents of dry weight such as skeletal muscle, fat, and bone density.MethodsSingle-center, prospective observational cohort study of medical ICU (MICU) patients from an academic institution in the USA. Five hundred and seven patients requiring CT scanning of chest or abdomen within the first 24 h of ICU admission were evaluated with erector spinae muscle (ESM) and subcutaneous adipose tissue (SAT) areas and with bone density determinations at the time of ICU admission, which were correlated with clinical outcomes accounting for potential confounders.ResultsLarger admission ESM area was associated with decreased odds of 6-month mortality (OR per cm2, 0.96; 95% CI, 0.94–0.97; p < 0.001) and disability at discharge (OR per cm2, 0.98; 95% CI, 0.96–0.99; p = 0.012). Higher bone density was similarly associated with lower odds of mortality (OR per 100 HU, 0.69; 95% CI, 0.49–0.96; p = 0.027) and disability at discharge (OR per 100 HU, 0.52; 95% CI, 0.37–0.74; p < 0.001). SAT area was not significantly associated with these outcomes’ measures. Multivariable modeling indicated that ESM area remained significantly associated with 6-month mortality and survival after adjusting for other covariates including preadmission comorbidities, albumin, functional independence before admission, severity scores, age, and exercise capacity.ConclusionIn our cohort, ICU admission skeletal muscle mass measured with ESM area and bone density were associated with survival and disability at discharge, although muscle area was the only component that remained significantly associated with survival after multivariable adjustments. SAT had no association with the analyzed outcome measures.

Value of the TTM risk score for early prognostication of comatose patients after out-of-hospital cardiac arrest in a Swiss university hospital.

Comatose patients admitted to the intensive care unit (ICU) after out-of-hospital cardiac arrest frequently die after withdrawal of life support. Guidelines recommend scheduling prognostication no sooner than 96 hours after cardiac arrest, and strict withdrawal criteria leave many patients waiting for improvement for days without ever reaching a favourable outcome. In clinical practice, physicians are frequently confronted with vague living wills expressed by next of kin or an imprecise advance care directive soon after cardiac arrest. Often a decision to admit a patient to an ICU or limiting ICU treatment in terms of time or intensity is made early, based on the patient&rsquo;s preferences. The Target Temperature Management (TTM) risk score is an imperfect measure that predicts outcome early, at the time of ICU admission. It was developed on a data set of 939 patients included in the TTM Trial, a study in which unconscious patients after cardiac arrest were randomised into two temperature management arms. Patient selection in that trial might impede generalisability. We aimed to validate the TTM risk score with 100 consecutive patients treated in our ICU. Although we had different survival rates, reflecting a different patient population, we were able to confirm the score&rsquo;s albeit imperfect ability to predict outcome early after cardiac arrest. The suggested cut-off values of 10 and 16 can be used as a basis for discussion with the family; in particular, a risk score value below 10 predicts a favourable outcome and might guide early discussion. As in the original study, the outcome of an individual patient cannot be predicted. (ClinicalTrials.gov Identifier: NCT02722460).

The effect of short-course antibiotics on the resistance profile of colonizing gut bacteria in the ICU: a prospective cohort study

BackgroundThe need for early antibiotics in the intensive care unit (ICU) is often balanced against the goal of antibiotic stewardship. Long-course antibiotics increase the burden of antimicrobial resistance within colonizing gut bacteria, but the dynamics of this process are not fully understood. We sought to determine how short-course antibiotics affect the antimicrobial resistance phenotype and genotype of colonizing gut bacteria in the ICU by performing a prospective cohort study with assessments of resistance at ICU admission and exactly 72 h later.MethodsDeep rectal swabs were performed on 48 adults at the time of ICU admission and exactly 72 h later, including patients who did and did not receive antibiotics. To determine resistance phenotype, rectal swabs were cultured for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). In addition, Gram-negative bacterial isolates were cultured against relevant antibiotics. To determine resistance genotype, quantitative PCR (qPCR) was performed from rectal swabs for 87 established resistance genes. Within-individual changes in antimicrobial resistance were calculated based on culture and qPCR results and correlated with exposure to relevant antibiotics (e.g., did β-lactam antibiotic exposure associate with a detectable change in β-lactam resistance over this 72-h period?).ResultsOf 48 ICU patients, 41 (85%) received antibiotics. Overall, there was no increase in the antimicrobial resistance profile of colonizing gut bacteria during the 72-h study period. There was also no increase in antimicrobial resistance after stratification by receipt of antibiotics (i.e., no detectable increase in β-lactam, vancomycin, or macrolide resistance regardless of whether patients received those same antibiotics). This was true for both culture and PCR. Antimicrobial resistance pattern at ICU admission strongly predicted resistance pattern after 72 h.ConclusionsShort-course ICU antibiotics made little detectable difference in the antimicrobial resistance pattern of colonizing gut bacteria over 72 h in the ICU. This provides an improved understanding of the dynamics of antimicrobial resistance in the ICU and some reassurance that short-course antibiotics may not adversely impact the stewardship goal of reducing antimicrobial resistance.

Outcomes of Intensive Care Patients Older Than 90 Years: An 11-Year National Observational Study.

Many intensive care unit (ICU) physicians are reluctant to admit patients aged 90 years and older, although evidence to support these decisions is scarce. Although the body of evidence on outcomes of patients aged 80 years and older is growing, it does not include patients aged 90 years and older. The aim of this study was to compare the short- and long-term mortality of ICU patients aged 90 years and older in the Netherlands with ICU patients aged 80 to 90 years, that is, octogenarians. Multicenter national cohort study over an 11-year period (2008-2018), using data of the National Intensive Care Evaluation (NICE) registry and the Dutch insurance claims registry. All 82 ICUs in the Netherlands. All patients aged 80 years and older at the time of ICU admission. A total of 104,754 patients aged 80 years and older, of whom 9,495 (9%) were 90 years and older, were admitted to Dutch ICUs during the study period. ICU mortality of the patients aged 90 years and older was lower (13.8% vs 16.1%; P < .001) and hospital mortality was similar (26.1% vs 25.7%; P = .41) compared with octogenarians. After 3 months, mortality was higher for the patients aged 90 years and older (43.1% vs 33.7%; P < .001) and after 1-year mortality was 55.0% vs 42.7%; P < .001. In the Netherlands, mortality rates of patients aged 90 years and older admitted to the ICU are not as disappointing as often assumed. They have a lower ICU mortality and a similar hospital mortality compared with octogenarians. Nevertheless, their longer term mortality is higher compared with octogenarians. However, almost 3 of 4 patients leave the hospital alive, and almost half of the patients aged 90 years and older are still alive 1 year after their ICU admission. J Am Geriatr Soc 68:1842-1846, 2020.

P0610ACUTE KIDNEY INJURY IN CRITICALLY ILL PATIENTS IN THE ICU

Abstract Background and Aims Acute kidney injury (AKI) is common and serious complication in critically ill patients in intensive care unit (ICU). The rapid increase in aging populations with more comorbidities contribute to high incidence AKI in ICU. Incidence varies from 20% to as high as 70%. AKI in the ICU frequently requires costly supportive therapies, has high morbidity and it’s associated with poor outcomes. We aimed to determine incidence of AKI, causes, risk factors, treatment and outcomes of AKI in critically ill patients in ICU. Method We collected data prospectively from case records of adult patients (older than 18 years of age) admitted to the ICU at the Department of Internal medicine, Emergency Center, Clinical center of Vojvodina in Novi Sad, Serbia, during 3 months. We included patients who had at least two measurements of serum creatinine. Data on patient demographics, diagnosis at the time of ICU admission, complete blood count, biochemistry, comorbidities (diabetes mellitus, arterial hypertension, other cardiovascular diseases, renal disease, prostate diseases, dehydration, burns, gastrointestinal bleeding, pancreatitis, peritonitis, sepsis), use of nephrotoxic agents, radiological procedures and treatment of AKI were recorded. We excluded patients with chronic renal disease who were on hemodialysis. There were no interventions. Results Of the 44 patients included in the study, median age was 67+/-13,20 years (range: 21 to 88). Of those 44 patients 20% developed AKI. De novo AKI was diagnosed in 51,22% of those patients and 48,78% had chronic renal failure in acutisation. The most frequent etiology was pre-renal, in 80,95% of patients. Renal origin and obstructive (post-renal) causes were detected in the same number of patients, 9,52%. Comorbidities were present present in all patients. Most common comorbidity was arterial hypertension, in 52,4% of patients, other cardiovascular diseases in 47,6 % of patients, sepsis also in 47,6% of patients and gastrointestinal bleeding in 33,3% of patients. Complete recovery of kidney function was detected in 42,86% of patients. Mortality was 28,57%. During the hospitalisation 90,48% of patients were treated conservative and 9,52% of patients required renal replacement therapy. Conclusion De novo AKI occurred in approximately half of the critically ill patients in ICU. The most frequent etiology was pre-renal. AKI was mainly detected in older patients with comorbidities. Age and comorbidities were also associated with the poor outcome. Mortality was high.

Clinical Comparison of Volume Support Ventilation With Pressure Support Ventilation in Patients Admitted at Intensive Care Unit

Mechanical ventilation (MV) is among the main basics of supportive treatment for respiratory failure in the intensive care unit (ICU). This supportive treatment may cause undesirable complications that led to the introduction of various MV modes. The current study was aimed to assess and compare outcomes of volume support ventilation (VSV) and pressure support ventilation (PSV) regarding spontaneous breath return, weaning and hemodynamic changes among patients admitted at ICU following surgical procedures. This single-blinded randomized-clinical-trial (RCT) was conducted on 100 patients admitted at ICU in 2018-2019. Patients were randomly divided into two fifty-member groups treated with PSV and VSV modes. Oxygen saturation, systolic (SBP) and diastolic blood pressure (DBP), mean arterial pressure (MAP), arterial blood gas (ABG), extubation and MV time and sedation based on RAMSY criteria were recorded and compared. Mean age (P=0.79) and gender distribution (P=0.57) were not statistically different in the two groups. Time has no effect on patients' hemodynamic (P&gt;0.05) while hemodynamic stability was superior in VSV (P&lt;0.05). ABG showed no statistical difference between groups (P&gt;0.05) except for arterial oxygen pressure that was higher in the VSV group (P&lt;0.001). The duration of MV, extubation time and duration of ICU admission was significantly lower in the VSV group. Furthermore, sedation based on RAMSY criteria showed the superiority of VSV (P&lt;0.05). Use of VSV mode was accompanied with superior outcomes in four entities including earlier and easier weaning, shorter duration of ICU admission, least hemodynamic instabilities and least sedation requirement in comparison to PSV mode. © 2019 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2019;57(7):416-423.

Epidemiological & clinical characteristics & early outcome of COVID-19 patients in a tertiary care teaching hospital in India: A preliminary analysis.

Background & objectives:In this study we describe the epidemiological data, comorbidities, clinical symptoms, severity of illness and early outcome of patients with coronavirus disease 2019 (COVID-19) from a tertiary care teaching hospital in New Delhi, India.Methods:In this preliminary analysis of a prospective observational study, all adult patients admitted to the screening intensive care unit (ICU) of the institute who fulfilled the WHO case definition of COVID-19 and confirmed to have SARS-CoV-2 infection by reverse transcription-polymerase chain reaction were included. Demographics, clinical data and 24 h outcome were assessed.Results:The preliminary analysis of 235 patients revealed that the mean age was 50.7±15.1 yr and 68.1 per cent were male. Fever (68.1%), cough (59.6%) and shortness of breath (71.9%) were the most common presenting symptoms. Hypertension (28.1%) and diabetes mellitus (23.3%) were the most common associated comorbid illnesses. Patients with mild, moderate, severe and critical illness were 18.3, 32.3, 31.1 and 18.3 per cent, respectively, at the time of ICU admission. The proportions (95% confidence interval) of patients requiring any form of oxygen therapy, oxygen therapy by high-flow nasal cannula and invasive mechanical ventilation were 77, 21.7 and 25.5 per cent, respectively, within 24 h of hospital admission. The 24 h ICU mortality was 8.5 per cent, and non-survivors had higher respiratory rate (P<0.01, n=198) and lower baseline oxyhaemoglobin saturation (P<0.001, n=198) at presentation and higher baseline serum lactate (P<0.01, n=122), total leucocyte count (P<0.001, n=186), absolute neutrophil count (P<0.001, n=132), prothrombin time (P<0.05, n=54) and INR (P<0.05, n=54) compared to survivors.Interpretation & conclusions:Nearly half of the patients presented with severe and critical disease and required high-flow nasal oxygen or invasive mechanical ventilation at admission. Severity of the presenting respiratory illness, haematological parameters and lactate rather than age or presence of comorbidity predicted early death within 24 h.

Development of an Algorithm to Predict Mortality in Patients With Sepsis and Coagulopathy.

Sepsis is a systemic response to infection with a high rate of mortality and complex pathophysiology involving inflammation, infection response, hemostasis, endothelium, and platelets. The purpose of this study was to develop an equation incorporating biomarker levels at intensive care unit (ICU) admission to predict mortality in patients with sepsis, based on the hypothesis that a combination of biomarkers representative of multiple physiological systems would provide improved predictive value. Plasma samples and clinical data were collected from 103 adult patients with sepsis at the time of ICU admission. Biomarker levels were measured using commercially available methods. A 28-day mortality was used as the primary end point. Stepwise linear regression modeling was performed to generate a predictive equation for mortality. Differences in biomarker levels between survivors were quantified using the Mann-Whitney test and the area under the receiver operating curve (AUC) was used to describe predictive ability. Significant differences (P < .05) were observed between survivors and nonsurvivors for plasminogen activator inhibitor 1 (AUC = 0.70), procalcitonin (AUC = 0.77), high mobility group box 1 (AUC = 0.67), interleukin (IL) 6 (AUC = 0.70), IL-8 (AUC = 0.70), protein C (AUC = 0.71), angiopoietin-2 (AUC = 0.76), endocan (AUC = 0.58), and platelet factor 4 (AUC = 0.70). A predictive equation for mortality was generated using stepwise linear regression modeling, which incorporated procalcitonin, vascular endothelial growth factor, the IL-6:IL-10 ratio, endocan, and platelet factor 4, and demonstrated a better predictive value for patient outcome than any individual biomarker (AUC = 0.87). The use of mathematical modeling resulted in the development of a predictive equation for sepsis-associated mortality with performance than any individual biomarker or clinical scoring system which incorporated biomarkers representative of multiple systems.

Preadmission Antiplatelet Use and Associated Outcomes and Costs Among ICU Patients With Intracranial Hemorrhage.

Patients with intracranial hemorrhage (including intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic hemorrhage) are commonly admitted to the intensive care unit (ICU). Although indications for oral antiplatelet agents are increasing, the impact of preadmission use on outcomes in patients with intracranial hemorrhage admitted to the ICU is unknown. We sought to evaluate the association between preadmission oral antiplatelet use, in-hospital mortality, resource utilization, and costs among ICU patients with intracranial hemorrhage. We retrospectively analyzed a prospectively collected registry (2011-2016) and included consecutive adult patients from 2 hospitals admitted to ICU with intracranial hemorrhage. Patients were categorized on the basis of preadmission oral antiplatelet use. We excluded patients with preadmission anticoagulant use. The primary outcome was in-hospital mortality and was analyzed using a multivariable logistic regression model. Contributors to total hospital cost were analyzed using a generalized linear model with log link and gamma distribution. Of 720 included patients with intracranial hemorrhage, 107 (14.9%) had been using an oral antiplatelet agent at the time of ICU admission. Oral antiplatelet use was not associated with in-hospital mortality (adjusted odds ratio: 1.31 [95% confidence interval [CI]: 0.93-2.22]). Evaluation of total costs also revealed no association with oral antiplatelet use (adjusted ratio of means [aROM]: 0.92 [95% CI: 0.82-1.02, P = .10]). Total cost among patients with intracranial hemorrhage was driven by illness severity (aROM: 1.96 [95% CI: 1.94-1.98], P < .001), increasing ICU length of stay (aROM: 1.05 [95% CI: 1.05-1.06], P < .001), and use of invasive mechanical ventilation (aROM: 1.76 [95% CI: 1.68-1.86], P < .001). Among ICU patients admitted with intracranial hemorrhage, preadmission oral antiplatelet use was not associated with increased in-hospital mortality or hospital costs. These findings have important prognostic implications for clinicians who care for patients with intracranial hemorrhage.

Factors Associated with Risk and Prognosis of Intensive Care Unit Admission in Patients with Acute Myeloid Leukemia: A Danish Nationwide Cohort Study

Significance Patients with acute myeloid leukemia (AML) are at high risk of critical illness requiring admission to the intensive care unit (ICU) due to both disease- and treatment-related complications. A better understanding of risk factors for ICU admission and prognosis may help with prevention of life-threatening complications and informed decision-making when treating AML patients. Methods This study included all adult Danish AML patients, who received remission-induction chemotherapy alone or in combination with allogeneic stem cell transplantation from 2005 to 2016. The cohort was identified using the Danish Acute Leukemia Registry (DNLR) and information on ICU admission was obtained from the Danish Intensive Care Database. We examined risk of ICU admission within 1 and 3 years of diagnosis considering competing risk of death and investigated a number of possible risk factors for ICU admission. We computed 1-, 3-, and 5-year mortality from time of ICU admission and in the matched non-ICU comparison group using a risk set matching (1:1) on time since diagnosis, sex, and age. Finally, we used the pseudo-value approach to compute the relative risk (RR) of death in the ICU admitted cohort compared to the matched cohort. We adjusted for ECOG/WHO performance status (PS), year of diagnosis, cytogenetic risk group, number of comorbidities, and secondary/therapy-related AML. Results A total of 1383 AML patients were included in the study. The median follow-up time was 1.65 (IQR: 0.60-4.36) years. The risk of ICU admission within 1 year of AML diagnosis was 22.7%, and the risk within 3 years was 28.1%. Median time to ICU was 59 (IQR: 15-272) days. Male sex was associated with increased risk of ICU admission after 1 year (adjusted RR: 1.26, 95% CI: 1.01-1.57) and PS &gt;1 was associated with an increased risk after both 1 year (adjusted RR: 1.74, 95% CI: 1.33-1.30) and 3 years (adjusted RR: 1.54, 95% CI: 1.22-1.96). Other factors listed in Table 1 (age, comorbidity, cytogenetic risk group, secondary or therapy-related AML, and year of diagnosis) were not associated with increased risk of ICU admission. In AML patients admitted to the ICU, the 1-year mortality from time of ICU admission was 69.2%, compared to a 1-year mortality rate of 31.0% in the matched non-ICU patients (adjusted RR: 3.25, 95% CI: 2.56-4.12). Long-term mortality was increased in ICU patients; 3-year mortality was 82.1% compared to 49.7% (adjusted RR: 2.43, 95% CI: 1.97-3.01), and the 5-year mortality was 83.1% compared to 60.6%, (adjusted RR: 2.12, 95% CI: 1.70-2.66). Conclusion In this national population-based cohort study, more than one fourth of AML patients treated with remission-induction chemotherapy were admitted to an ICU within 3 years of diagnosis with the majority of ICU admissions occurring within the first year. ICU admission was associated with high mortality, especially within the first year after admission. The risk of mortality decreased over time but remained increased 3 and 5 years after admission compared to the matched cohort. Early monitoring and management of high-risk patients may be effective in preventing ICU admissions and PS may serve as a possible tool to identify patients at high risk of ICU admission. Disclosures No relevant conflicts of interest to declare.

Association of intensive care unit occupancy during admission and inpatient mortality: a retrospective cohort study.

There is conflicting evidence regarding the influence of intensive care unit (ICU) occupancy at the time of admission on important patient outcomes such as mortality. The objective of this analysis was to characterize the association between ICU occupancy at the time of ICU admission and subsequent mortality. This single-centre, retrospective cohort study included all patients admitted to the ICU at the Vancouver General Hospital between 4 January 2010 and 8 October 2017. Intensive care unit occupancy was defined as the number of ICU bed hours utilized in a day divided by the total amount of ICU bed hours available for that day. We constructed mixed-effects logistic regression models controlling for relevant covariates to assess the impact of admission occupancy quintiles on total inpatient (ICU and ward) and early (72-hr) ICU mortality. This analysis included 10,365 ICU admissions by 8,562 unique patients. Compared with ICU admissions in the median occupancy quintile, admissions in the highest and second highest occupancy quintile were associated with a significant increase in the odds of inpatient mortality (highest: odds ratio [OR], 1.33; 95% confidence interval [CI], 1.12 to 1.59; P value < 0.001; second highest: OR, 1.21; 95% CI, 1.02 to 1.44; P value < 0.03). No association between admission occupancy and 72-hr ICU mortality was observed. Admission to the ICU on days of high occupancy was associated with increased inpatient mortality, but not with increased 72-hr ICU mortality. Capacity strain on the ICU may result in significant negative consequences for patients, but further research is needed to fully characterize the complex effects of capacity strain.

Correlation between Serum Magnesium and Lactate Levels at the Time of ICU Admission and Early Phase of Sepsis

Background: As the fourth abundant electrolyte in the body, magnesium has critical roles in aerobic metabolism and regulation of the immune system. Few studies investigate the association between magnesium status of critically ill septic patients and lactate acidosis in the intensive care unit (ICU). In this study, serum magnesium level and lactate level were evaluated at both admission time and time of sepsis. Methods: This was a prospective, cross-sectional study conducted at general ICU of a tertiary referral teaching hospital. Hypomagnesemia was defined as a serum magnesium concentration of less than 1.7 mg/dL. Mann-Whitney test and independent-sample t-test were used to analyze nonparametric and parametric data, respectively. Results: Of 50 sepsis patients, 32 patients were normomagnesemic, and 18 were hypomagnesemic. Hypomagnesemic patients have significantly higher lactate serum level at the time of sepsis compared to normomagnesemic patients [2.32 (1.96-3.29) vs. 1.94 (1.80-2.15) mg/dl respectively, p&lt;0.001]. There were significant differences between normomagnesemic and hypomagnesemic septic patients in Acute Physiology and Chronic Health Evaluation (APACHE) II score at sepsis time (9.44 ± 4.33 vs. 11.67 ± 3.83, p=0.46), and Sequential Organ Failure Assessment (SOFA) score [3 (3.00-5.00) vs. 4 (3.75-6.25), p=0.04]. Also, 28-day mortality because of sepsis (50% respectively, p&lt;0.001), duration of mechanical ventilation [12.00 (4.00-14.25) days respectively, p&lt;0.01] and ICU stay [14.00 (12.75-17.25) days respectively, p&lt;0.01] were significantly higher in hypomagnesemic groups. Conclusion: Admission hypomagnesemia in sepsis patients may increase serum lactate concentration, duration of ventilation, duration of ICU stay and mortality.

Association between endotoxemia and enterocyte injury and clinical course in patients with gram-positive septic shock: A posthoc analysis of a prospective observational study.

Endotoxemia often occurs in patients with gram-positive infections. The possible mechanism is thought to be bacterial translocation after enterocyte hypoperfusion injury. However, the association between endotoxemia and enterocyte injury among patients with gram-positive septic shock has never been assessed. The aim of this study was to evaluate the association between endotoxemia and enterocyte injury in gram-positive septic shock patients and to evaluate the association among endotoxemia, subsequent clinical course, and other related factors.This was a posthoc analysis of a prospective observational study that evaluated the capability of intestinal fatty acid-binding protein (I-FABP), an indicator of enterocyte injury, to predict mortality. Among 57 patients in septic shock, those whose causative microorganisms were gram positive were included. The correlation between endotoxin activity (EA), which indicates endotoxemia, and I-FABP levels upon admission to the intensive care unit (ICU), the clinical course, and other related factors were evaluated.A total of 21 patients were examined. One-third of the patients presented with high EA levels at the time of ICU admission. However, there was no significant correlation between EA and I-FABP levels (Spearman ρ = 0.002, P = .993). Additionally, high EA levels were not associated with abdominal complications after ICU admission or mortality. Similarly, high EA levels were not associated with severity scores, inotropic scores, or lactate levels upon ICU admission, which were previously reported to be factors related to high EA levels.In this posthoc analysis, no correlation was observed between endotoxemia and enterocyte injury among patients in gram-positive septic shock. Additionally, high EA levels were not associated with the clinical course and reported factors related to endotoxemia. Although our results need to be validated in a large prospective cohort study, hypoperfusion enterocyte injury might not be a cause of endotoxemia in these patients. Thus, if there is no correlation between EA and I-FABP levels, other mechanisms that induce high EA levels among patients with gram-positive septic shock should be elucidated.

Impact of hypophosphatemia on outcome of patients in intensive care unit: a retrospective cohort study

BackgroundHypophosphatemia generally occurs in Intensive Care Units (ICUs), but its impact is often ignored. The aim of this study was to investigate whether hypophosphatemia can be a risk factor for ICU 28-day mortality.MethodsA single-center retrospective cohort study was conducted by collecting data from 1073 patients admitted to general ICU and then presented to the Sixth Affiliated Hospital, Sun Yat-sen University (Guangzhou City, Guangdong Province, China) from 1 January 2016 to 31 December 2017. The patients were divided into a normal control group (serum phosphate levels 0.80–1.60 mmol/L) and a hypophosphatemia group (serum phosphate levels < 0.80 mmol/L), based on the concentration of phosphorus at the time of ICU admission. The association between phosphate levels and ICU 28-day mortality was evaluated by binary logistic regression analysis. Multivariate logistic regression was employed to predict the ICU 28-day mortality.ResultsThe cohort included 946 patients with a median phosphate concentration of 0.77 mmol/L (interquartile range 0.55–1.03 mmol/L). Patients with hypophosphatemia had a higher ICU 28-day mortality than the normal control group (33.3% vs 24.0%, P < 0.05). Patients with hypophosphatemia had a longer ICU and hospital stays, and prolonged duration of mechanical ventilation (all P < 0.05). Hypophosphatemia was an independent risk factor for ICU 28-day mortality (adjusted OR = 1.5, 95% CI = 1.1–2.1, P = 0.01) in the multivariate logistic regression analysis.ConclusionsHypophosphatemia at admission is an independent risk factor for 28-day mortality in general ICU patients.Trial registrationThe medical study was approved by the Institutional Ethics Committee of the Six Affiliated Hospital, Sun Yat-sen University (Approval number: 2017ZSLYEC-110). No consent was given as the data were analyzed anonymously.

Post-intensive care syndrome: its pathophysiology, prevention, and future directions.

Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long‐term prognoses. Post‐intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long‐term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS‐p) and the mental status of their family (PICS‐F). Intensive care unit‐acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow‐up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS.