Effect of focused cardiopulmonary ultrasonography on clinical outcome of septic shock: a randomized study

ObjectiveTo investigate the effect of focused ultrasonography on clinical outcomes of septic shock.MethodsPatients with septic shock were randomized into an integrated cardiopulmonary ultrasonography (ICUS) group and conventional (CON) group. Within 1 hour of admission, the ICUS group underwent ICUS examination for hemodynamic decision-making, while the CON group received standard treatment. The primary endpoint was 28-day mortality after admission. The secondary endpoints were cumulative fluid administration in the first 6, 24, and 72 hours; use of vasoactive drugs; lactate clearance; duration of ventilation; and ICU stay.ResultsNinety-four qualified patients were enrolled (ICUS group, 49; CON group, 45). ICUS showed no significant effect on 28-day mortality. Within the initial 6 hours, the ICUS group tended to have a higher fluid balance and fluid intake than the CON group. The duration of vasopressor support was shorter in the ICUS group. There were no differences in the cumulative fluid infusion within 24 or 72 hours, lactate clearance, ICU stay, or duration of ventilation.ConclusionsThe initially focused ICUS did not affect the clinical outcomes of septic shock, but it tended to be associated with a higher fluid balance within the initial 6 hours and shorter duration of vasopressor support.     

Healthcare utilization and mortality outcomes in patients with pre-existing psychiatric disorders after intensive care unit discharge: A population-based retrospective cohort study

PurposePre-existing psychiatric disorders may lead to negative outcomes following intensive care unit (ICU) discharge. We evaluated the association of pre-existing psychiatric disorders with subsequent healthcare utilization and mortality in patients discharged from ICU.Materials and methodsWe retrospectively studied adult patients admitted to 14 medical-surgical ICUs (January 2014–June 2016) with ICU length stay ≥24 h who survived to hospital discharge. Pre-existing psychiatric disorders were identified using algorithms for diagnostic codes captured ≤5 years before ICU admission. Outcomes were healthcare utilization (emergency department visit, hospital or ICU readmission) and mortality. We used logistic regression models with propensity scores to estimate associations, converted to risk ratios (RR).ResultsWe included 10,598 patients. 37.6% (n = 3982) had a psychiatric history. Patients with pre-existing psychiatric disorders were at higher risk of subsequent emergency department visits (RR 1.49, 95%CI 1.29–1.71), hospital readmission (RR 1.49, 95%CI 1.34–1.66), ICU readmission (RR 2.64, 95%CI 1.55–4.49) one-year post-ICU discharge, compared to patients without pre-existing psychiatric disorders. Patients with pre-existing psychiatric disorders had a higher risk of mortality (RR 1.31, 95%CI 1.00–1.71) six-months post-ICU discharge.ConclusionCritically ill patients with pre-existing psychiatric disorders have an increased risk of healthcare utilization and mortality outcomes following an ICU stay.     

The impact of the addition of nurse practitioners to surgical intensive care units: A retrospective cohort study

BackgroundDemand for surgical critical care is increasing, but work-hour restrictions on residents have affected many hospitals. Recently, the use of nurse practitioners (NPs) as providers in the intensive care unit (ICU) has expanded rapidly, although the impacts on quality of care have not been evaluated.ObjectivesTo compare the outcomes of critically ill surgical patients before and after the addition of NPs to the ICU team.MethodsWe conducted a retrospective cohort study in a Taiwanese surgical ICU. We compared the outcomes of patients admitted to ICU during the 2-year period before and after the addition of NPs to the ICU team. Patients admitted in the 1-year transition phase were excluded from comparisons. The primary endpoint was ICU mortality. Secondary endpoints included ICU length of stay and incidence of unplanned extubation.ResultsA total of 8747 patients were included in the study. For all eligible admissions, primary and secondary outcomes did not differ significantly between the two groups. For scheduled ICU admissions, ICU mortality was significantly lower after the addition of NPs (2.2% before vs. 1.1% after addition of NPs, p = 0.014). For unscheduled ICU admissions, ICU mortality did not differ significantly between the two groups. In the multivariate analysis, admission after the addition of NPs was associated with significantly reduced ICU mortality (odds ratio = 0.481; 95% confidence interval = 0.263–0.865; p = 0.015) among scheduled admissions.ConclusionIncorporating NPs in the ICU team was associated with improved outcomes in scheduled admissions to surgical ICU when compared with a traditional, resident-based team.     

Physical capacities assessment in critically ill patients: An exploratory study

BackgroundThe severity of muscle weakness after critical illness is very heterogeneous. To identify those patients who may maximally benefit from early exercises would be highly valuable. This implies an assessment of physical capacities, comprised at least of strength measurement and functional tests.ObjectivesThe objective of this study was to investigate the relationship between muscle strength and functional tests in an intensive care unit (ICU) setting.MethodsAdults with ICU length of stay ≥2 days were included. Handgrip strength (HG) and maximal isometric quadriceps strength (QS) were assessed using standardised protocols as soon as patients were alert and able to obey commands. At the same time, their maximal level of mobilisation capabilities and their autonomy were assessed using ICU Mobility Scale (ICU-MS) and Barthel Index, respectively.ResultsNinety-three patients with a median age of 64 [57–71.5] years, body mass index of 26.4 [23.4–29.6] kg/m², and Simplified Acute Physiology Score II of 33 [27.7–41] were included. Absolute and relative QS were, respectively, 146.7 [108.5–196.6] N and 1.87 [1.43–2.51] N/kg. HG was 22 [16–31] kg. The ICU-MS score was 4 [1–5]. A significant positive correlation was observed between HG and absolute QS (r_s = 0.695, p < 0.001) and between HG and relative QS (r_s = 0.428, p < 0.001). The ICU-MS score correlated with HG, with a weak positive relationship (r_s = 0.215, p = 0.039), but not with QS. The ICU-MS score did not statistically differ between the weakest and strongest patients for absolute or relative QS, but was lower in patients with the lowest HG values (p = 0.01). A weak positive correlation was observed between the Barthel Index and muscle strengths (maximum r_s = 0.414, p < 0.001).ConclusionsThe present results suggest that, during ICU stay, there is no strong association between muscle strength and functional test such as the ICU-MS or Barthel Index. Muscle dynamometry and functional tests are probably complementary tools for physical capacities quantification.     

Acute kidney injury in Indigenous intensive care patients

BackgroundPatients presenting to intensive care units (ICUs) report high rates of acute kidney injury (AKI) requiring renal replacement therapy (RRT). Globally, Indigenous populations report higher rates of renal disease than their non-Indigenous counterparts.ObjectivesThis study reports the prevalence, presenting features, and outcomes of Indigenous ICU admissions with AKI (who require RRT) within an Australian ICU setting and compares these with those of Indigenous patients without AKI.MethodA retrospective database review examined all Indigenous patients older than 18 years admitted to a regional Australian ICU between June 2013 and June 2016, excluding patients with chronic kidney disease requiring dialysis. We report patient demography, presenting clinical and physiological characteristics, ICU length of stay, hospital outcome, and renal requirements at three months after discharge, on Indigenous patients with AKI requiring RRT.ResultsAKI requiring RRT was identified in 15.9% of ICU Indigenous patients. On univariate analysis, it was found that these patients were older and had a higher body mass index, lower urine output, and higher levels of creatinine and urea upon presentation than patients who did not have AKI. Patients with AKI reported longer ICU stays and a higher mortality rate (30%, p < 0.05), and 10% of these required ongoing RRT at 3 months. Multivariate analysis found significant associations with AKI were only found for presenting urine outputs, urea and creatinine levels.ConclusionsThis study reports higher rates of AKI requiring RRT for Indigenous adults than non-Indigenous adults, as has been previously published. Benefits arising from this study are as follows: these reported findings may initiate early targeted clinical management and can assist managing expectations, as some patients may require ongoing RRT after discharge.     

Physical activity of patients with critical illness undergoing rehabilitation in intensive care and on the acute ward: An observational cohort study

BackgroundThere are limited published data on physical activity of survivors of critical illness engaged in rehabilitation in hospital, despite it plausibly influencing outcome.ObjectiveThe aims of this study were to measure physical activity of patients with critical illness engaged in rehabilitation in the intensive care unit (ICU) and on the acute ward and report discharge destination, muscle strength, and functional outcomes.MethodsThis was a single-centre, prospective observational study. Adults with critical illness, who received ≥48 h of invasive mechanical ventilation, and who were awake and able to participate in rehabilitation were eligible. To record physical activity, participants wore BodyMedia SenseWear Armbands (BodyMedia Incorporated, USA), during daylight hours, from enrolment until hospital discharge or day 14 of ward stay (whichever occurred first). The primary outcome was time (minutes) spent performing physical activity at an intensity of greater than 1.5 Metabolic Equivalent Tasks. Secondary outcomes included discharge destination, muscle strength, and physical function.ResultsWe collected 807 days of physical activity data (363 days ICU, 424 days ward) from 59 participants. Mean (standard deviation) duration of daily physical activity increased from the ICU, 17.8 (22.8) minutes, to the ward, 52.8 (51.2) minutes (mean difference [95% confidence interval] = 35 [23.8–46.1] minutes, P < .001). High levels of activity in the ICU were associated with higher levels of activity on the ward (r = .728), n = 48, P < .001.ConclusionsPatients recovering from critical illness spend less than 5% of the day being physically active throughout hospital admission, even when receiving rehabilitation. Physical activity increased after discharge from intensive care, but had no relationship with discharge destination. Only the absence of ICU-acquired weakness on awakening was associated with discharge directly home from the acute hospital. Future studies could target early identification of ICU-acquired weakness and the preservation of muscle strength to improve discharge outcomes.     

The needs of patients with post–intensive care syndrome: A prospective,observational study

BackgroundThe needs of critical illness survivors and how best to address these are unclear.ObjectivesThe objective of this study was to identify critical illness survivors who had developed post–intensive care syndrome and to explore their use of community healthcare resources, the socioeconomic impact of their illness, and their self-reported unmet healthcare needs.MethodsPatients from two intensive care units (ICUs) in Western Australia who were mechanically ventilated for 5 days or more and/or had a prolonged ICU admission were included in this prospective, observational study. Questionnaires were used to assess participants' baseline health and function before admission, which were then repeated at 1 and 3 months after ICU discharge.ResultsFifty participants were enrolled. Mean Functional Activities Questionnaire scores increased from 1.8 out of 30 at baseline (95% confidence interval [CI]: 0–3.5) to 8.9 at 1 month after ICU discharge (95% CI: 6.5–11.4; P = <0.001) and 7.0 at 3 months after ICU discharge (95% CI: 4.9–9.1; P = < 0.001). Scores indicating functional dependence increased from 8% at baseline to 54% and 33% at 1 and 3 months after ICU discharge, respectively. Statistically significant declines in health-related quality of life were identified in the domains of Mobility, Personal Care, Usual Activities, and Pain/Discomfort at 1 month after ICU discharge and in Mobility, Personal Care, Usual Activities, and Anxiety/Depression at 3 months after ICU discharge. An increase in healthcare service use was identified after ICU discharge. Participants primarily identified mental health services as the service that they felt they would benefit from but were not accessing. Very low rates of return to work were observed, with 35% of respondents at 3 months, indicating they were experiencing financial difficulty as a result of their critical illness.ConclusionsStudy participants developed impairments consistent with post–intensive care syndrome, with associated negative socioeconomic ramifications, and identified mental health as an area they need more support in.     

Association of early-onset constipation and diarrhoea with patient outcomes in critically ill ventilated patients: A retrospective observational cohort study

BackgroundConstipation and diarrhoea are closely related, but few studies have examined them simultaneously.ObjectivesThe purpose of this study was to describe patient defecation status after intensive care unit (ICU) admission and determine the association between early-onset constipation and diarrhoea following ICU admission with outcomes for critically ill ventilated patients.MethodsPatients ventilated for ≥48 h in an ICU were retrospectively investigated, and their defecation status was assessed during the first week after admission. Early-onset constipation and diarrhoea were defined as onset during the first week of ICU admission. The patients were divided into three groups—normal defecation, constipation, and diarrhoea—and multiple comparisons were performed using the Kruskal–Wallis test and the Mann–Whitney U test with Bonferroni adjustment. Additionally, multivariable analysis was performed for mortality and length of stay using the linear and logistic regression models.ResultsOf the 85 critically ill ventilated patients, 47 (55%) experienced early-onset constipation and 12 (14%) experienced early-onset diarrhoea. Patients with normal defecation and diarrhoea increased from the 4th and 5th day of ICU admission. Early-onset diarrhoea was significantly associated with the length of ICU stay (B = 7.534, 95% confidence interval: 0.116–14.951).ConclusionsEarly-onset constipation and diarrhoea were common in critically ill ventilated patients, and early-onset diarrhoea was associated with the length of ICU stay.     

Time for critically ill patients to regain mobility after early mobilization in the intensive care unit and transition to a general inpatient floor

PurposeThe purpose of this study is to determine if patient mobility achievements in an intensive care unit (ICU) setting are sustained during subsequent phases of hospitalization, specifically after transferring to inpatient floors and on the day of hospital discharge.Materials and MethodsThe study is an analysis of adult patients who stayed in the ICU for 48 hours or more during the second quarter of 2013. The study sample included 182 patients who transferred to a general inpatient floor after the ICU stay.ResultsPatients experienced an average delay of 16 hours to regain or exceed chair level of mobility and 7 hours to regain ambulation level after transferring to an inpatient floor. One third of patients ambulated in the ICU, and those patients had significantly shorter post-ICU and hospital stays compared with patients who did not ambulate in the ICU. Delays in regaining mobility on the floor were modestly associated with initial Morse Fall Score and being male.ConclusionsMobility progression through the hospital course is imperative to improving patient outcomes. Study findings show the need for improvement in maintaining early ICU mobilization achievement during the crucial phase between ICU stay and hospital discharge.     

Clinical and economic burden of bloodstream infections in critical care patients with central venous catheters

PurposeBloodstream infections (BSIs) complicate the management of intensive care unit (ICU) patients. We assessed the clinical and economic impact of BSI among patients of a managed care provider group who had a central venous catheter (CVC) placed in the ICU.MethodsWe considered hospitalizations occurring between January 1, 2011, and September 30, 2014, that involved an ICU stay during which a CVC was placed. Comparisons were made between episodes where the patient did vs did not develop BSI after CVC insertion. Length of stay, costs of index hospitalization, and total costs over the 180 days after discharge were compared using linear mixed models. Inhospital mortality and 30-day readmission rates were compared using negative binomial regression models.ResultsDevelopment of BSI was associated with longer hospital stay (+ 7 days), more than 3-fold increase in risk of inhospital death, and an additional $129 000 in costs for the index hospitalization. No statistically significant differences in 30-day readmission rates or costs of care over the 180-day period after discharge from the index admission were observed.ConclusionBloodstream infections after CVC placement in ICU patients are associated with significant increases in costs of care and risk of death during the index hospitalization but no differences in readmissions or costs after discharge.     

The effect of family-authored diaries on posttraumatic stress disorder in intensive care unit patients and their relatives: A randomised controlled trial (DRIP-study)

BackgroundCritical illness and mechanical ventilation may cause patients and their relatives to experience symptoms of posttraumatic stress, anxiety, and depression due to fragmentation of memories of their intensive care unit (ICU) stay. Intensive care diaries authored by nurses may help patients and relatives process the experience and reduce psychological problems after hospital discharge; however, as patients particularly appreciate diary entries made by their relatives, involving relatives in authoring the diary could prove beneficial.ObjectivesThe objective of this study was to explore the effect of a diary authored by a close relative for a critically ill patient.MethodsThe study was a multicenter, block-randomised, single-blinded, controlled trial conducted at four medical-surgical ICUs at two university hospitals and two regional hospitals. Eligible for the study were patients ≥18 years of age, undergoing mechanical ventilation for ≥24 h, staying in the ICU ≥48 h, with a close relative ≥18 years of age. A total of 116 relatives and 75 patients consented to participate. Outcome measures were scores of posttraumatic stress symptoms, anxiety, depression, and health-related quality of life three months after ICU discharge.ResultsRelatives had 26.3% lower scores of posttraumatic stress in the diary group than in the control group (95% confidence interval: 4.8–% to 52.2%). Patients had 11.2% lower scores of posttraumatic stress symptoms in the diary group (95% confidence interval: −15.7% to 46.8%). There were no differences between groups in depression, anxiety, or health-related quality of life.ConclusionA diary written by relatives for the ICU patient reduced the risk of posttraumatic stress symptoms in relatives. The diary had no effect on depression, anxiety, or health-related life quality. However, as the diary was well received by relatives and proved safe, the diary may be offered to relatives of critically ill patients during their stay in the ICU.     

Factors associated with a persistent delirium in the intensive care unit: A retrospective cohort study

PurposeTo explore differences between ICU patients with persistent delirium (PD), non-persistent delirium (NPD) and no delirium (ND), and to determine factors associated with PD.Materials and methodsRetrospective cohort study including all ICU adults admitted for ≥12 h (January 2015–February 2020), assessable for delirium and followed during their entire hospitalization. PD was defined as ≥14 days of delirium. Factors associated with PD were determined using multivariable logistic regression analysis.ResultsOut of 10,295 patients, 3138 (30.5%) had delirium, and 284 (2.8%) had PD. As compared to NPD (n = 2854, 27.7%) and ND (n = 7157, 69.5%), PD patients were older, sicker, more physically restrained, longer comatose and mechanically ventilated, had a longer ICU and hospital stay, more ICU readmissions and a higher mortality rate.Factors associated with PD were age (adjusted odds ratio [aOR] 1.03; 95% confidence interval [CI] 1.02–1.04); emergency surgical (aOR 1.84; 95%CI 1.26–2.68) and medical (aOR 1.57; 95%CI 1.12–2.21) referral, mean Sequential Organ Failure Assessment (SOFA) score before delirium onset (aOR 1.18; 95%CI 1.13–1.24) and use of physical restraints (aOR 5.02; 95%CI 3.09–8.15).ConclusionsPatients with persistent delirium differ in several characteristics and had worse short-term outcomes. Physical restraints were the most strongly associated with PD.     

Risk factors for prolonged intensive care unit stays in patients after cardiac surgery with cardiopulmonary bypass: A retrospective observational study

ObjectivesPatients after cardiac surgery with cardiopulmonary bypass (CPB) require a stay in the ICU postoperatively. This study aimed to investigate the incidence of prolonged length of stay (LOS) in the ICU after cardiac surgery with CPB and identify associated risk factors.MethodsThe current investigation was an observational, retrospective study that included 395 ICU patients who underwent cardiac surgery with CPB at a tertiary hospital in Guangzhou from June 2015 to June 2017. Data were obtained from the hospital database. Binary logistic regression modeling was used to analyze risk factors for prolonged ICU LOS.ResultsOf 395 patients, 137 (34.7%) had a prolonged ICU LOS (>72.0 h), and the median ICU LOS was 50.9 h. Several variables were found associated with prolonged ICU LOS: duration of CPB, prolonged mechanical ventilation and non-invasive assisted ventilation use, PaO₂/FiO₂ ratios within 6 h after surgery, type of surgery, red blood cell infusion during surgery, postoperative atrial arrhythmia, postoperative ventricular arrhythmia (all P < 0.05).ConclusionsThese findings are clinically relevant for identifying patients with an estimated prolonged ICU LOS, enabling clinicians to facilitate earlier intervention to reduce the risk and prevent resulting delayed recovery.     

Impact of obstructive sleep apnea on the obesity paradox in critically ill patients

ObjectivePatients admitted to an intensive care unit (ICU) frequently suffer from multiple chronic diseases, including obstructive sleep apnea (OSA). Until recently OSA was not considered as a key determinant in an ICU patient's prognosis. The objective of this study was to document the impact of OSA on the prognosis of ICU patients.MethodsData were retrospectively collected concerning adult patients admitted to ICU at two university hospitals. In a nested study OSA status was checked using the hospital electronic medical records to identify exposed and unexposed cases. The following outcomes were considered: length of stay in the ICU, ICU mortality, in-hospital mortality, ventilator-associated pneumonia (VAP).ResultsOut of 5146 patients included in the study, 289 had OSA at ICU admission (5.6%). After matching, the overall impact of OSA on length of ICU stay was not significant (p = .24). In a predefined subgroup analysis, there was a significant impact of OSA on the length of ICU stay for patients with BMI over 40 kg/m² (IRR: 1.56 [1.05; 2.32], p = .03). OSA status had no impact on ICU or hospital mortality and VAP.ConclusionIn general, known OSA did not increase the ICU stay except for patients with both OSA and morbid obesity.     

Evolución de la fuerza muscular en paciente críticos con ventilación mecánica invasiva

ObjectiveTo assess the evolution of muscle strength in critically ill patients with mechanical ventilation (MV) from withdrawal of sedatives to hospital discharge.Material and methodA cohort study was conducted in two intensive care units in the Hospital Universitari de Bellvitge from November 2011 to March 2012. Inclusion criteria: Consecutive patients with MV > 72 h. Dependent outcome: Muscle strength measured with the Medical Research Council (MRC) scale beginning on the first day the patient was able to answer 3 out of 5 simple orders (day 1), every week, at ICU discharge and at hospital discharge or at day 60 Independent outcomes: factors associated with muscle strength loss, ventilator-free days, ICU length of stay and hospital length of stay. The patients were distributed into two groups (MRC< 48, MRC ≥ 48) after the first measurement.ResultsThirty-four patients were assessed. Independent outcomes associated with muscle strength weakness were: days with cardiovascular SOFA >2 (P<.001) and days with costicosteroids (P<.001). Initial MRC in MRC<48 group was 38 (27-43), and 52 (50-54) in MRC ≥ 48. The largest muscle strength gain was obtained the first week (31% versus 52%). A MRC < 48 value was associated with more MV days (P<.007) and a longer ICU stay. (P<.003).ConclusionThe greatest muscle strength gain after withdrawing of the sedatives was achieved in the first week. Muscle strength loss was associated with a cardiovascular SOFA > 2 and costicosteroids. Patients with a MRC < 48 required more days with MV and a longer ICU stay.     

Mechanical ventilation and mortality among 223 critically ill patients with coronavirus disease 2019: A multicentric study in Germany

BackgroundThere are large uncertainties with regard to the outcome of patients with coronavirus disease 2019 (COVID-19) and mechanical ventilation (MV). High mortality (50–97%) was proposed by some groups, leading to considerable uncertainties with regard to outcomes of critically ill patients with COVID-19.ObjectivesThe aim was to investigate the characteristics and outcomes of critically ill patients with COVID-19 requiring intensive care unit (ICU) admission and MV.MethodsA multicentre retrospective observational cohort study at 15 hospitals in Hamburg, Germany, was performed. Critically ill adult patients with COVID-19 who completed their ICU stay between February and June 2020 were included. Patient demographics, severity of illness, and ICU course were retrospectively evaluated.ResultsA total of 223 critically ill patients with COVID-19 were included. The majority, 73% (n = 163), were men; the median age was 69 (interquartile range = 58–77.5) years, with 68% (n = 151) patients having at least one chronic medical condition. Their Sequential Organ Failure Assessment score was a median of 5 (3–9) points on admission. Overall, 167 (75%) patients needed MV. Noninvasive ventilation and high-flow nasal cannula were used in 31 (14%) and 26 (12%) patients, respectively. Subsequent MV, due to noninvasive ventilation/high-flow nasal cannula therapy failure, was necessary in 46 (81%) patients. Renal replacement therapy was initiated in 33% (n = 72) of patients, and owing to severe respiratory failure, extracorporeal membrane oxygenation was necessary in 9% (n = 20) of patients. Experimental antiviral therapy was used in 9% (n = 21) of patients. Complications during the ICU stay were as follows: septic shock (40%, n = 90), heart failure (8%, n = 17), and pulmonary embolism (6%, n = 14). The length of ICU stay was a median of 13 days (5–24), and the duration of MV was 15 days (8–25). The ICU mortality was 35% (n = 78) and 44% (n = 74) among mechanically ventilated patients.ConclusionIn this multicentre observational study of 223 critically ill patients with COVID-19, the survival to ICU discharge was 65%, and it was 56% among patients requiring MV. Patients showed high rate of septic complications during their ICU stay.     

Lower mean phosphate independently predicts mortality in critically ill patients: Results from a prospective cohort study

PurposeTo evaluate lower mean phosphate as a prognostic tool in critically ill patients.MethodsThis is a prospective single-center cohort study including adult patients (> 18 years) with a length of intensive care unit (ICU) stay of at least 24 h. Phosphatemia was evaluated within 1 h of ICU admission and once daily. Mean phosphate, calculated by the simple arithmetic mean of daily phosphate measurements, was proposed and tested. Standard severity scores were applied. Multivariate and survival analyses were performed.ResultsA total of 317 patients were included, of whom 111 (35%) presented hypophosphatemia. Hypophosphatemia associated with surgical conditions, nutritional therapy, hypovitaminosis D, hyperparathyroidism, mechanical ventilation (need and duration), and ICU and hospital length of stay were evaluated. Admission APACHE II and SOFA (ICU days 1, 3, and 7) scores and ICU and in-hospital mortality were greater in the hypophosphatemia group than control group. Higher APACHE II (RR: 1.1; 95%CI: 1.01–1.2; p = 0.045) and lower mean phosphate (RR: 0.02; 95%CI: 0.001–0.09; p = 0.044) independently predicted ICU and in-hospital mortality.ConclusionsHypophosphatemia is frequent in the ICU, and was associated with unfavorable outcomes. This study introduces the importance of longitudinal monitoring of phosphate levels, since lower mean phosphate is an independent predictor of mortality in critically ill patients.     

One-year survival in patients with solid tumours discharged alive from the intensive care unit after unplanned admission: A retrospective study

PurposeOutcomes in cancer patients after unplanned ICU admission was reassessed.Methodsretrospective cohort of patients with solid tumours admitted to ICU over a 10 years period.Results622 patients (age 62 [53–70]) were analysed. The most common primary sites of cancer were lung (n = 133; 21.4%) and digestive tract (n = 126; 20.2%) The ICU mortality rate was 22.2% (n = 138). Among 470 ICU survivors, the 1-year mortality was 41.3% (95% CI, 36–45.9) (n = 167). Factors independently associated with 1-year mortality were ICU admission after 2010 (HR 0.53 (0.37–0.76), p < .001), disease status (respectively, HR = 1.88 (1.0.2–3.45), p = .002) for locally advanced cancer and HR = 2.23 (1.35–3.67), p = .003) for metastatic cancer), poor performance status (HR = 1.58 (1.08–2.31), p = .019), newly diagnosed cancer at ICU admission (HR = 2.02 (1.28–3.20), p = .003), inability to receive oncologic treatment after ICU discharge (HR = 5.34 (3.49–8.18), p < .001) and decision to withhold life-sustaining treatment during ICU stay (HR = 2.34 (1.50–3.65), p < .001).ConclusionsAmong the factors associated with one-year mortality after ICU discharge, the possibility of receiving oncologic treatment after ICU discharge seems crucial.     

International variation in length of stay in intensive care units and the impact of patient-to-nurse ratios

ObjectiveTo assess variation in ICU length of stay between countries with varying patient-to-nurse ratios; to compare ICU length of stay of individual countries against an international benchmark.DesignSecondary analysis of the DecubICUs trial (performed on 15 May 2018).SettingThe study cohort included 12,794 adult ICU patients (57 countries). Only countries with minimally twenty patients discharged (or deceased) within 30 days of ICU admission were included.Main outcome measureMultivariate Cox regression was used to evaluate ICU length of stay, censored at 30 days, across countries and for patient-to-nurse ratio, adjusted for sex, age, admission type and Simplified Acute Physiology Score II. The resulting hazard ratios for countries, indicating longer or shorter length of stay than average, were plotted on a forest plot. Results by country were benchmarked against the overall length of stay using Kaplan-Meier curves.ResultsPatients had a median ICU length of stay of 11 days (interquartile range, 4–27). Hazard ratio by country ranged from minimally 0.42 (95% confidence interval 0.35–0.51) for Greece, to maximaly1.94 (1.28–2.93) for Lithuania. The hazard ratio for patient-to-nurse was 0.96 (0.94–0.98), indicating that higher patient-to-nurse ratio results in longer length of stay.ConclusionsDespite adjustment for case-mix, we observed significant heterogeneity of ICU length of stay in-between countries, and a significantly longer length of stay when patient-to-nurse ratio increases. Future studies determining underlying characteristics of individual ICUs and broader organisation of healthcare infrastructure within countries may further explain the observed heterogeneity in ICU length of stay.