ICU Resource Use Research Articles

Strain on the ICU resources and patient outcomes in the COVID-19 pandemic: A Swedish national registry cohort study.

The Coronavirus 2019 (COVID-19) pandemic has led to an unprecedented strain on the ICU resources. It is not known how the ICU resources employed in treating COVID-19 patients are related to inpatient characteristics, use of organ support or mortality. To investigate how the use of ICU resources relate to use of organ support and mortality in COVID-19 patients. A national register-based cohort study. All Swedish ICUs from March 2020 to November 2021. All patients admitted to Swedish ICUs with a primary diagnosis of COVID-19 reported to the national Swedish Intensive Care Register (SIR). Organ support (mechanical ventilation, noninvasive ventilation, high-flow oxygen therapy, prone positioning, surgical and percutaneous tracheostomy, central venous catheterisation, continuous renal replacement therapy and intermittent haemodialysis), discharge at night, re-admission, transfer and ICU and 30-day mortality. Seven thousand nine hundred and sixty-nine patients had a median age of 63 years, and 70% were men. Median daily census was 167% of habitual census, daily new admissions were 20% of habitual census and the median occupancy was 82%. Census and new admissions were associated with mechanical ventilation, OR 1.37 (95% CI 1.28 to 1.48) and OR 1.44 (95% CI 1.13 to 1.84), respectively, but negatively associated with noninvasive ventilation, OR 0.83 (95% CI 0.77 to 0.89) and OR 0.40 (95% CI 0.30 to 52) and high-flow oxygen therapy, OR 0.72 (95% CI 0.67 to 0.77) and OR 0.77 (95% CI 0.61 to 0.97). Occupancy above 90% of available beds was not associated with mechanical ventilation or noninvasive ventilation, but with high-flow oxygen therapy, OR 1.36 (95% CI 1.21 to 1.53). All measures of pressure on resources were associated with transfer to other hospitals, but none were associated with discharge at night, ICU mortality or 30-day mortality. Pressure on ICU resources was associated with more invasive respiratory support, indicating that during these times, ICU resources were reserved for sicker patients.

The use of ICU resources in CAR-T cell recipients: a hospital-wide study

BackgroundCAR-T cell (chimeric antigen receptor T) therapy has emerged as an effective treatment of refractory hematological malignancies. Intensive care management is intrinsic to CAR-T cell therapy. We aim to describe and to assess outcomes in critically ill CAR-T cell recipients.Study design and methodsHospital-wide retrospective study. Consecutive CAR-T cell recipients requiring ICU admission from July 2017 and December 2020 were included.Results71 patients (median age 60 years [37–68]) were admitted to the ICU 6 days [4–7] after CAR-T cell infusion. Underlying malignancies included diffuse large B cell lymphoma (n = 53, 75%), acute lymphoblastic leukemia (17 patients, 24%) and multiple myeloma (n = 1, 1.45%). Performance status (PS) was 1 [1–2]. Shock was the main reason for ICU admission (n = 40, 48%). Isolated cytokine release syndrome (CRS) was the most common complication (n = 33, 46%), while 21 patients (30%) had microbiologically documented bacterial infection (chiefly catheter-related infection). Immune effector cell-associated neurotoxicity syndrome was reported in 26 (37%) patients. At ICU admission, vasopressors were required in 18 patients (25%) and invasive mechanical ventilation in two. Overall, 49 (69%) and 40 patients (56%) received tocilizumab or steroids, respectively.Determinant of mortality were the reason for ICU admission (disease progression vs. sepsis or CRS (HR 4.02 [95%CI 1.10–14.65]), Performance status (HR 1.97/point [95%CI 1.14–3.41]) and SOFA score (HR 1.16/point [95%CI 1.01–1.33]).ConclusionsMeaningful survival could be achieved in up to half the CAR-T cell recipients. The severity of organ dysfunction is a major determinant of death, especially in patients with altered performance status or disease progression.

Adoption of the use of a reflective blanket for passive re-warming of the stable mildly hypothermic patient to reduce unnecessary ICU admissions: A pilot study

Background and objective: In adult inpatients, thermoregulation is important to support vital functions. Occasionally, due to procedures or benign clinical conditions, such as hypoglycemia, autonomic instability, brain injury, paraplegia, autonomic dysreflexia, and septic shock, patients’ body temperature falls below 35°C and thus, requires intervention. Due to the floor nursing constraints of hourly monitoring of forced air re-warming, these active warming techniques often lead to clinically unnecessary admissions to intensive care units and utilization of scarce and costly resources. The purpose of this pilot study was to explore passive re-warming with alternative technologies to avoid unnecessary admissions to the intensive care unit.Methods: A pilot study based on a sample of seventeen patients was conducted to assess the adoption and associated outcome of the use of the reflective blanket. Intervention: Application of a reflective blanket to patients who were mildly hypothermic, yet clinically stable, was explored as an effective mechanism to re-warm these patients in the non-intensive care unit setting. Results: The investigation based on the use of a reflective blanket on a sample of seventeen hypothermic patients had a success rate of 0.7059 (70.59%).Conclusions: We conclude that the use of a reflective blanket is an effective and safe passive rewarming mechanism that leads to avoidance of unnecessary intensive care unit admissions. This leads to both cost reductions to patients and appropriate use of ICU resources.

Utility of NT-proBNP as an objective marker of postoperative heart failure after coronary artery bypass surgery: a prospective observational study

BackgroundPostoperative heart failure (PHF) is the main cause for mortality after cardiac surgery but unbiased evaluation of PHF is difficult. We investigated the utility of postoperative NT-proBNP as an objective marker of PHF after coronary artery bypass surgery (CABG).MethodsProspective study on 382 patients undergoing isolated CABG for acute coronary syndrome. NT-proBNP was measured preoperatively, the first (POD1) and third postoperative morning (POD3). A blinded Endpoints Committee used prespecified criteria for PHF. Use of circulatory support was scrutinized.ResultsAfter adjusting for confounders PHF was associated with 1.46 times higher NT-proBNP on POD1 (p = 0.002), 1.54 times higher on POD3 (p < 0.0001). In severe PHF, NT-proBNP was 2.18 times higher on POD1 (p = 0.001) and 1.81 times higher on POD3 (p = 0.019). Postoperative change of NT-proBNP was independently associated with PHF (OR 5.12, 95% CI 1.86–14.10, p = 0.002). The use of inotropes and ICU resources increased with incremental quartiles of postoperative NT-proBNP.ConclusionsPostoperative NT-proBNP can serve as an objective marker of the severity of postoperative myocardial dysfunction. Due to overlap in individuals, NT-proBNP is useful mainly for comparisons at cohort level. As such, it provides a tool for study purposes when an unbiased assessment of prevention or treatment of PHF is desirable.Trial registrationClinicalTrials.gov Identifier: NCT00489827https://clinicaltrials.gov/ct2/show/NCT00489827?term=glutamics&draw=2&rank=1.

Impact of Nonpharmaceutical Interventions on ICU Admissions During Lockdown for Coronavirus Disease 2019 in New Zealand-A Retrospective Cohort Study.

OBJECTIVES:Nonpharmaceutical interventions are implemented internationally to mitigate the spread of severe acute respiratory syndrome coronavirus 2 with the aim to reduce coronavirus disease 2019–related deaths and to protect the health system, particularly intensive care facilities from being overwhelmed. The aim of this study is to describe the impact of nonpharmaceutical interventions on ICU admissions of non–coronavirus disease 2019–related patients.DESIGN:Retrospective cohort study.SETTING:Analysis of all reported adult patient admissions to New Zealand ICUs during Level 3 and Level 4 lockdown restrictions from March 23, to May 13, 2020, in comparison with equivalent periods from 5 previous years (2015–2019).SUBJECTS:Twelve-thousand one-hundred ninety-two ICU admissions during the time periods of interest were identified.MEASUREMENTS:Patient data were obtained from the Australian and New Zealand Intensive Care Society Adult Patient Database, Australian and New Zealand Intensive Care Society critical care resources registry, and Statistics New Zealand. Study variables included patient baseline characteristics and ICU resource use.MAIN RESULTS:Nonpharmaceutical interventions in New Zealand were associated with a 39.1% decrease in ICU admission rates (p < 0.0001). Both elective (–44.2%) and acute (–36.5%) ICU admissions were significantly reduced when compared with the average of the previous 5 years (both p < 0.0001). ICU occupancy decreased from a mean of 64.3% (2015–2019) to 39.8% in 2020. Case mix, ICU resource use per patient, and ICU and hospital mortality remained unchanged.CONCLUSIONS:The institution of nonpharmaceutical interventions was associated with a significant decrease in elective and acute ICU admissions and ICU resource use. These findings may help hospitals and health authorities planning for surge capacities and elective surgery management in future pandemics.

Characteristics and Outcomes of 4,942 Critically Ill Adult Patients with COVID-19 in Brazil

Background: The spread of COVID-19 increased the stress of health systems globally, obligating adjustments to improve the management of severe cases. What are the impacts of preparedness measures on the outcomes of the COVID-19 critically ill patients? Our study aimed to analyze the clinical characteristics, resource use, and risk factors associated with 30-day in-hospital mortality of critically ill adult patients with COVID-19 requiring ICU admission in a network of Brazilian hospitals.Methods: A multicenter cohort of COVID-19-confirmed patients requiring ICU admission at 42 Brazilian hospitals between February 27th and June 27th, 2020. The primary outcome was 30-day in-hospital mortality. We evaluated the association of clinical characteristics, ICU resource use, and risk factors using a random-effects multivariable cox regression model, in which the hospital was the random intercept. Secondary outcomes were the length-of-stay, ICU, and in-hospital mortality, and the use of mechanical ventilation during hospitalization.Findings: From 4,942 patients, 713 (14·4%) died 30 days after the ICU admission. The median age was 56 (IQR: [43,72]) years, 38% of patients were over 60 years-old, and 41% were women. Being older than 70 years (70-79, Hazard Ratio [95%CI]: 1·95[1·3-2·93]; ≥ 80, 3·96[2·66-5·89]), frail (MFI≥3, 1·65 [1·26-2·15]) and requiring, early or late, invasive Mechanical Ventilation (48h, 3·26 [2·46-4·32]) were independently associated with 30-day mortality. In 1,400 ventilated patients, 30-day mortality was 44·4% (622/1,400), the median duration of mechanical ventilation was ten days (IQR [6,16]), and ICU length of stay was 17 days (IQR [10,26]). Those who died within 30 days were more often older than 80 years (≥80: 37% vs. 14%) and previously frail (35% vs. 19%) compared to the survivors.Interpretation: In this large cohort, critically ill COVID-19 patients showed reasonable survival rates, including those requiring mechanical ventilation. Factors associated with worse outcome were age, frailty, and early need for invasive ventilation. Adequate preparedness, early hospitalization, and no shortage of critical care resources were probably key to achieve such results.Funding: The National Council for Scientific and Technological Development (CNPq); the Coordination for the Improvement of Higher Education Personnel (CAPES); the Carlos Chagas Filho Foundation for Research Support of the State of Rio de Janeiro (FAPERJ); the Pontifical Catholic University of Rio de Janeiro and the D’Or Institute for Research and Education.Declaration of Interests: Dr. Soares and Dr. Salluh are founders and equity shareholders of Epimed Solutions®, which commercializes the Epimed Monitor System®, a cloud-based software for ICU management and benchmarking. The other authors declare that they have no conflict of interest.Ethics Approval Statement: Local Ethics Committee and the Brazilian National Ethics Committee (CAAE: 17079119.7.0000.5249) approved the study without the need for informed consent.

The Coronavirus Disease 2019 Pandemic’s Effect on Critical Care Resources and Health-Care Providers: A Global Survey

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide.Research QuestionHow do regional differences and perceived lack of ICU resources affect critical care resource use and the well-being of HCPs?Study Design and MethodsBetween April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout.ResultsWe included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction [ARR], 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46).InterpretationOur findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.

Shifting Paradigms in Head and Neck Reconstructive Surgery During the COVID-19 Crisis.

Shifting Paradigms in Head and Neck Reconstructive Surgery During the COVID-19 Crisis.

Critical Care Management of Chimeric Antigen Receptor T Cell–related Toxicity. Be Aware and Prepared

CAR (chimeric antigen receptor) T cells (CARTs) are genetically engineered T cells that express CARs, with impressive clinical activity in relapsed and refractory hematologic malignancies, primarily acute lymphoblastic leukemia and diffuse large B-cell lymphoma. The most frequent life-threatening adverse events after CART infusion are cytokine release syndrome and CAR-related encephalopathy syndrome, which can occur within hours or days after administration. IL-6 released by macrophages and monocytes plays a major role in the pathogenesis of cytokine release syndrome and CAR-related encephalopathy syndrome, and IL-6 blockade and steroids contribute to fast resolution of symptoms. Critical care management plays an important role in patients receiving CARTs, as up to half of patients might need an admission to the ICU and lifesaving interventions. As new treatment indications and CART constructs enter the clinic, the number of patients requiring ICU admission will rapidly increase, with profound consequences for the use of ICU resources, training requirements, clinical expertise, multidisciplinary collaboration, and hospital organization. Research is also needed to validate at large scale biomarkers that allow doctors to risk-stratify patients for both their risk to develop severe toxicity and their likelihood to respond to therapy.

Initiation of Noninvasive Ventilation for Acute Respiratory Failure in a Pediatric Intermediate Care Unit.

Noninvasive ventilation (NIV) is increasingly used to manage acute respiratory failure in children, decreasing the need for mechanical ventilation. Safely managing these patients outside of the ICU improves ICU resource use. We measured the impact of a guideline permitting initiation of NIV in an intermediate care unit (IMCU) on ICU bed use. A guideline for an NIV trial for acute respiratory failure was implemented in a 10-bed IMCU. The guideline stipulated criteria for initiation and maintenance of NIV. There were 4.5 years of intervention data collected. Baseline data were gathered for patients with acute respiratory failure who were transferred from the IMCU to the ICU for NIV initiation in the 3.25 years before guideline implementation. Three hundred eight patients were included: 101 in the baseline group and 207 in the intervention group. In the intervention group, 143 patients (69%) remained in the IMCU after NIV initiation, and 64 (31%) transferred to the ICU. A total of 656.4 ICU bed-days were saved in the intervention period (3.3 days per patient initiated on NIV in the IMCU). There was a significant decrease in the rate of intubation in the IMCU for patients awaiting ICU transfer (3 patients in the baseline group versus 0 patients in the intervention group; P = .035). The initiation of NIV in the IMCU for pediatric patients with acute respiratory failure saved ICU bed-days without increasing intubation in the IMCU for patients awaiting transfer. Close monitoring of these critically ill patients is a key component of their safe care.

Ten-year trends in intensive care admissions for respiratory infections in the elderly

BackgroundThe consequences of the ageing population concerning ICU hospitalisation need to be adequately described. We believe that this discussion should be disease specific. A focus on respiratory infections is of particular interest, because it is strongly associated with old age. Our objective was to assess trends in demographics over a decade among elderly patients admitted to the ICU for acute respiratory infections.MethodsA cross-sectional study was performed between 2006 and 2015 based on hospital discharge databases in one French region (2.5 million inhabitants). Patients with acute respiratory infection were selected according to the specific ICD-10 diagnosis codes recorded, including acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP). We also identified comorbid conditions based on any significant ICD-10 secondary diagnoses adapted from the Charlson and Elixhauser indexes.ResultsA total of 98,381 hospital stays for acute respiratory infection were identified among the 3,856,785 stays over the 10-year period. The number of patients 75 y/o and younger increased 1.6-fold from 2006 to 2015, whereas the numbers of patients aged 85–89 and ≥ 90 y/o increased by 2.5- and 2.1-fold, respectively. Both CAP and AECOPD hospitalisations significantly increased for all age groups over the decade. ICU hospitalisations for respiratory infection increased 2.7-fold from 2006 to 2015 (p = 0.0002). The greatest increases in the use of ICU resources were for the 85–89 and ≥ 90 y/o groups, which corresponded to increases of 3.3- and 5.8-fold. Indeed, the proportion of patients hospitalized for respiratory infection in ICU that were elderly clearly grew during the decade: 11.3% were ≥ 85 y/o in 2006 versus 16.4% in 2015 (p < 0.0001). This increase in ICU hospitalisation rate of ageing patients was not associated with significant changes in the level of care or ICU mortality except for patients ≥ 90 y/o (for whom ICU mortality dropped from 40.9 to 22.3%, p = 0.03).ConclusionWe observed a substantial increase in acute respiratory infection diagnoses associated with hospitalisation between 2006 and 2015, with a growing demand for critical care services. Both the absolute number and the percentage of elderly patient ICU admissions increased over the last decade, with the greatest increases being observed for patients 85 years and older.

Endothelial Cell-Specific Molecule-1 in Critically Ill Patients With Hematologic Malignancy.

To assess whether serum concentration of endothelial cell-specific molecule-1 (Endocan) at ICU admission is associated with the use of ICU resources and outcomes in critically ill hematology patients. Prospective multicenter cohort study. Seventeen ICUs in France and Belgium. Seven hundred forty-four consecutive critically ill hematology patients; 72 critically ill septic patients without hematologic malignancy; 276 healthy subjects. None. Median total endocan concentrations were 4.46 (2.7-7.8) ng/mL. Endocan concentrations were higher in patients who had received chemotherapy before ICU admission (4.7 [2.8-8.1] ng/mL vs. 3.7 [2.5-6.3] ng/mL [p = 0.002]). In patients with acute respiratory failure, endocan levels were increased in patients with drug-induced pulmonary toxicity compared with other etiologies (p = 0.038). Total endocan levels higher than 4.46 ng/mL were associated with a higher cumulative probability of renal replacement therapy requirement (p = 0.006), a higher requirement of mechanical ventilation (p = 0.01) and a higher requirement of vasopressors throughout ICU stay (p < 0.0001). By multivariate analysis, total endocan levels at admission were independently associated with ICU mortality (odds ratios, 1.39; 95% CI, 1.06-1.83; p = 0.018). The predictive value of endocan peptide fragments of 14 kDa in terms of mortality and life-sustaining therapies requirement was inferior to that of total endocan. Endocan levels were higher in critically ill hematology patients compared with healthy subjects (p < 0.0001) but lower than endocan values in critically ill septic patients without hematologic malignancy (p = 0.005) CONCLUSIONS:: Serum concentrations of endocan at admission are associated with the use of ICU resources and mortality in critically ill hematology patients. Studies to risk-stratify patients in the emergency department or in the hematology wards based on endocan concentrations to identify those likely to benefit from early ICU management are warranted.

Potentially modifiable factors contributing to sepsis-associated encephalopathy.

Identifying modifiable factors for sepsis-associated encephalopathy may help improve patient care and outcomes. We conducted a retrospective analysis of a prospective multicenter database. Sepsis-associated encephalopathy (SAE) was defined by a score on the Glasgow coma scale (GCS) <15 or when features of delirium were noted. Potentially modifiable risk factors for SAE at ICU admission and its impact on mortality were investigated using multivariate logistic regression analysis and Cox proportional hazard modeling, respectively. We included 2513 patients with sepsis at ICU admission, of whom 1341 (53%) had sepsis-associated encephalopathy. After adjusting for baseline characteristics, site of infection, and type of admission, the following factors remained independently associated with sepsis-associated encephalopathy: acute renal failure [adjusted odds ratio (aOR)=1.41, 95% confidence interval (CI) 1.19-1.67], hypoglycemia <3mmol/l (aOR=2.66, 95% CI 1.27-5.59), hyperglycemia >10mmol/l (aOR=1.37, 95% CI 1.09-1.72), hypercapnia >45mmHg (aOR=1.91, 95% CI 1.53-2.38), hypernatremia >145mmol/l (aOR=2.30, 95% CI 1.48-3.57), and S.aureus (aOR=1.54, 95% CI 1.05-2.25). Sepsis-associated encephalopathy was associated with higher mortality, higher use of ICU resources, and longer hospital stay. After adjusting for age, comorbidities, year of admission, and non-neurological SOFA score, even mild alteration of mental status (i.e., a score on the GCS of 13-14) remained independently associated with mortality (adjusted hazard ratio=1.38, 95% CI 1.09-1.76). Acute renal failure and common metabolic disturbances represent potentially modifiable factors contributing to sepsis-associated encephalopathy. However, a true causal relationship has yet to be demonstrated. Our study confirms the prognostic significance of mild alteration of mental status in patients with sepsis.

Early Bispectral Index and Sedation Requirements During Therapeutic Hypothermia Predict Neurologic Recovery Following Cardiac Arrest*

To test the hypothesis that low bispectral index scores and low sedative requirements during therapeutic hypothermia predict poor neurologic outcome. Observational study of a prospectively collected cohort. Cardiovascular ICU. One hundred sixty consecutive cardiac arrest patients treated with therapeutic hypothermia. None. Eighty-four of the 141 subjects (60%) who survived hypothermia induction were discharged from the ICU with poor neurologic outcome, defined as a cerebral performance category score of 3, 4, or 5. These subjects had lower bispectral index (p < 0.001) and sedative requirements (p < 0.001) during hypothermia compared with the 57 subjects discharged with good outcome. Early prediction of neurologic recovery was best 7 hours after ICU admission, and median bispectral index scores at that time were 31 points lower in subjects discharged with poor outcome (11 [interquartile range, 4-29] vs 42 [37-49], p < 0.001). Median sedation requirements decreased by 17% (interquartile range, -50 to 0%) 7 hours after ICU admission in subjects with poor outcome but increased by 50% (interquartile range, 0-142%) in subjects with good outcome (p < 0.001). Each 10-point decrease in bispectral index was independently associated with a 59% increase in the odds of poor outcome (95% CI, 32-76%; p < 0.001). The model including bispectral index and sedative requirement correctly reclassified 15% of subjects from good to poor outcome and 1% of subjects from poor to good outcome. The model incorrectly reclassified 1% of subjects from poor to good outcome but did not incorrectly reclassify any from good to poor outcome. Bispectral index scores and sedative requirements early in the course of therapeutic hypothermia improve the identification of patients who will not recover from brain anoxia. The ability to accurately predict nonrecovery after cardiac arrest could facilitate discussions with families, reduce patient suffering, and limit use of ICU resources in futile cases.

Causes and consequences of disproportionate care in intensive care medicine

Increased use of advanced life-sustaining measures in patients with poor long-term expectations secondary to more chronic organ dysfunctions, comorbidities and/or a poor quality of life has become a worrying trend over the last decade. This can lead to futile, disproportionate or inappropriate care in the ICU. This review summarizes the causes and consequences of disproportionate care in the ICU. Disproportionate care seems to be common in European and North American ICUs. The initiation and prolongation of disproportionate care can be related to hospital facilities, healthcare providers, the patient and his/her representatives and society. This can have serious consequences for patients, their relatives, physicians, nurses and society. Disproportionate care is common in western ICUs. It can lead to violation of basic bioethical principles, suffering of patients and relatives and compassion fatigue and moral distress in healthcare providers. Avoiding inappropriate use of ICU resources and disproportionate care in the ICU should have high priority for ICU managers but also for every healthcare provider taking care of patients at the bedside.

HIV patients admitted to an ICU of a university hospital - experience of 15 years: 1995 to 2009

HIV infection is a major public health problem in the world. The use of prophylaxis against opportunist infection and the introduction of HAART in 1996 increased life expectancies. The therapeutic use of ICU resources for HIV patients has been controversial, questioning the admission of these patients especially in advanced stages of the disease, given the poor prognosis. The aim of this study was to determine the experience of the past 15 years in relation to the income of these patients in an ICU.

Changes in the epidemiology and prediction of multiple-organ failure after injury

The epidemiology of multiple-organ failure (MOF) after injury has been changing, questioning the validity of previously described prediction models. This study aimed to describe the current epidemiology of MOF. The secondary aim was development of a prediction model that could be used for early identification of patients at risk of MOF. A 60-month prospective epidemiologic study was undertaken at an Australian Level I trauma center. Data were collected on trauma patients that met inclusion criteria (intensive care unit [ICU] admission; Injury Severity Score [ISS] > 15; age > 18 years, head Abbreviated Injury Scale [AIS] score < 3; and survival for >48 hours). Demographics, injury severity (ISS), physiologic parameters, MOF status based on the Denver score, and outcome data were prospectively collected. Univariate analysis and multivariate logistic modeling were performed; p < 0.05 was considered significant. Data are presented as percentage or mean (SD). A total of 140 patients met the inclusion criteria (age, 47 [21] years; ISS, 30 [11]; male, 69%), 21 patients (15%) developed MOF, and MOF associated mortality was 24% versus non-MOF mortality rate of 3%. Patients who developed MOF had longer ICU stays (19 [7] vs. 7 [5], p < 0.01) and had more ventilator days (18 [9] vs. 4 [4], p < 0.01). Prediction models were generated at two time points as follows: admission and 24 hours after injury. At admission, age (>65 years) and admission platelet count (<150 × 10(9)/L) were significant predictors of MOF; at 24 hours after injury, MOF was predicted by age more than 65 years, admission platelet count less than 150 × 10(9)/L, maximum creatinine of greater than 150 × 10(9)/L and minimum bilirubin of greater than 10 × 10(9)/L. Shock parameters and injury severity did not predict MOF. The incidence of MOF (15%) is lower than reported 15 years ago; MOF remains a major cause of ICU resource use and late mortality after injury. The independent predictors of MOF have fundamentally changed, likely owing to improvements in resuscitation and critical care. Current predictors are universally available at admission and 24 hours. Epidemiologic/prognostic study, level III.

Prognostic scoring indicator in evaluation of clinical outcome in intestinal perforations.

Acute generalised peritonitis coming forth due to underlying intestinal perforation is a critical & life-threatening medical condition. It is a common surgical emergency most of the times across the world. Misleading data on crude morbidity and mortality due to the condition usually contaminates substantially the very purpose of medical audit. Thus, early prognostic evaluation is not only desirable but mandate to much extent. High-risk patients require timely & aggressive treatment especially in severe peritonitis & to select them reasonably well, evaluation through prognostic scoring is an approach of choice. Well sought after & reasonably reliable APACHE II scoring system is used for the purpose & scores are correlated well to accentuate & measure the various factors needed for better management of condition. The study was conducted over the period of 18 months (Jan 2010 to June 2011) on 50 patients with confirmed diagnosis of intestinal perforation. APACHE II score was calculated and correlated with their symptoms & clinical outcomes regarding morbidity and mortality. APACHE II score correlated well with the outcome of the study, showing score affects of two major aspects in the treatment outcome & management.1.) APACHE II score of less than 10 included 30 low risk group patients discharged in a satisfactory gratifying manner. Three out of four in high risk group with APACHE II score >20, shown adverse outcomes. 2.)Mean ICU stay of 9.75 days was found in patients with APACHE II score 20 or more compared to those with mean ICU stay of 0.13 days in patients with APACHE II score 10 or less. Acute generalized peritonitis being life-threatening medical emergency requires careful consideration in its management that needs to be economically viable, acceptably feasible and outcome oriented with better allocation & utilization of ICU resources that needs meticulous case analysis & prioritization. This present study helps the clinicians in three major ways: a) To take better decisions on case to case basis; b) To design strategies in order to prevent adverse outcomes; c) Last but not least, to make better use of ICU resources.

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Introduction: There are 7 million undiagnosed diabetics in the US although the number in the ICU remains poorly defined. The use of hemoglobin A1C is validated for the diagnosis of diabetes and its application presents an opportunity to identify unknown diabetics in the ICU. Hypothesis: To determine the prevalence and characteristics of unknown diabetics in the ICU. Methods: A prospective observational study of 4535 consecutive patients admitted to 8 ICUs in an academic medical center and hybrid academic/community hospital. 3841 (77%) had an A1C drawn during their admission. Patients with A1C >6.5 were examined for a history of anti-hyperglycemic medications/ICD-9 diagnosis of diabetes to determine if they were uncontrolled or unknown diabetics. Patients with A1C <6.5 were examined for history of anti-hyperglycemic medications/ICD-9 diagnosis of diabetes to determine if they were non-diabetics or controlled diabetics. This led to four groups: non-diabetics, controlled diabetics, uncontrolled diabetics and unknown diabetics. Results: 451(12.9%) patients were undiagnosed diabetics,2231 (64.1%) were non-diabetics, 400 (11.5%) were controlled diabetics and 399 (11.5%) were uncontrolled diabetics. The average A1C (blood glucose)was 8.21 (156) for unknown diabetics, 5.48 (131) for the non-diabetics, 5.51 (142) for the controlled diabetics and 8.62 (165) for the uncontrolled diabetics. Glucose readings were significantly different with 75.6% of unknown diabetics within a range of 70-180 compared with 89.8% of non-diabetics, 80.4% of controlled diabetics and 68.2% of uncontrolled diabetics. Unknown diabetics also had more hyperglycemic episodes 23%, than non-diabetics 8.5% and controlled diabetics 17.3% but less than uncontrolled diabetics 29.7%. Unknown diabetics were more likely to need insulin infusions 53%, than non-diabetics 30.8% and controlled diabetics 32.5% but less than uncontrolled diabetics 56.1%. Conclusions: Undiagnosed diabetics represent a significant percentage of the ICU population and significant challenges in glycemic control and ICU resource use. The use of A1C in this population represents a opportunity to identify and engage this patient population.

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Introduction: Therapeutic hypothermia (TH) is now widely used worldwide in the management of post-cardiac arrest encephalopathy. Due to the use of limited ICU resources, there has also been a search for predictors with the required specificity as early as possible after cardiac arrest so futile treatment can be terminated; however, the reliability of predictors that can identify TH candidates remains unknown. Hypothesis: We can develop a prediction rule to predict the neurological outcome of TH patients; clinical predictors are obtained before patients underwent TH. Methods: We performed a single-center retrospective cohort study over 12 years (2001-2012). Inclusion criteria were out-of-hospital cardiac arrest of cardiac origin, successful return of spontaneous circulation and induction of therapeutic hypothermia. Data were abstracted from the charts included demographics, characteristics of cardiac arrest, clinical variables on hospital arrival and subsequent interventions. Outcome measure was neurological status at hospital discharge (cerebral-performance category [CPC]). Backward elimination of non-significant variables was used to identify the important predictors in a stepwise logistic regression model. The beta-coefficient of each of the predictors was used to build a score. We tested the discriminative power of prediction scores using receiver-operator characteristic (ROC) curve analysis with the area under the curve (AUC). Results: Of 72 eligible patients, 44 (61.1%) had favorable outcome (CPC1-2) and 28 (38.9%) had poor outcome (CPC3-5). Four variables were identified as important predictors of poor outcome (age >= 60 yrs, cardiac arrest in the home, absence of pupillary reflex on hospital arrival and CPR duration >= 20 min). The integer score of 2 was assigned for age >= 60 yrs and absence of pupillary reflex, and the integer score of 1 assigned for cardiac arrest in the home and CPR duration >= 20 min, weighted by beta-coefficient values. ROC analysis showed an AUC was 0.92 (95% confidence interval [CI], 0.87-0.98) and identified a prediction score >= 5 as an optimal cut-off point, with a sensitivity of 0.61 (95% CI, 0.50-0.64), specificity of 0.98 (95% CI, 0.91-1.00) and positive predictive value of 0.94 (95% CI, 0.78-0.99), negative predictive value of 0.80 (95% CI, 0.74-0.81) for predicting poor outcome. Conclusions: Our prediction rule was valid to identify futility of TH in patients after cardiac arrest. This tool requires external validation study.