Mortality in healthy elderly patients after ICU admission

Purpose  The aim of this study was to assess mortality in healthy elderly patients after non-elective medical ICU admission and to identify predictive factors of mortality in these patients. Methods  Patients ≥65 years living at home and with full-autonomy (Barthel index, BI > 60), without cognitive impairment, and non-electively admitted to a medical ICU were prospectively recruited. A full comprehensive geriatric assessment was made with validated scales. Results  A total of 230 patients were included, 110 (48%) between 65 and 74 years and 120 (52%) ≥75 years. No significant differences were observed between the two groups in premorbid functional and cognitive status, main diagnosis at ICU admission, APACHE II and SOFA scores, use of mechanical ventilation or haemodialysis or length of ICU stay. Over a mean follow-up of 522 days (range 20–1,170 days) the cumulative mortality of the whole group was 55%, being significantly higher in older subjects (62 vs. 47%; P = 0.024). On multivariate analysis, only parameters related to quality of life (QOL) and functional status were independent predictors of cumulated mortality (P < 0.01, both). Thus, in patients with EQ-5D_vas (<70) or baseline Lawton index (LI) (<5) the hazard ratio for cumulated mortality was 2.45 (95% CI: 1.15–5.25; P = 0.03) and 4.10 (95% CI: 1.53–10.99; P = 0.006), respectively, compared to those with better scores. Conclusions  Healthy elderly non-elective medical patients admitted to the ICU have a high mortality rate related to premorbid QOL. The LI and/or EQ-5D_vas may be useful tools to identify patients with the best chance of survival.     

Impact of increased calls to rapid response systems on unplanned ICU admission

BackgroundWhether hospital bed number and rapid response system (RRS) call rate is associated with the clinical outcomes of patients who have RRS activations is unknown. We test a hypothesis that hospital volume and RRS call rates are associated with the clinical outcomes of patients with RRSs.MethodsThis is a retrospective chart analysis of an existing dataset associated with In-Hospital Emergency Registry in Japan. In the present study, 4818 patients in 24 hospitals from April 2014 to March 2018 were analyzed. Primary outcome variable was an unplanned intensive care unit (ICU) admission after RRS activation.ResultsIn the primary analysis of the study using a multivariate analysis adjusting potential confounding factors, higher RRS call rate was significantly associated with decreased unplanned ICU admissions (P < 0.0001, Odds ratio [OR] 0.95, 95% confidence interval [CI] 0.92–0.98), but there was no significant association of hospital volume with unplanned ICU admissions (P = 0.44). In the secondary analysis of the study, there was a non-significant trend of increased cardiac arrest on arrival at the location of the RRS provider at large-volume hospitals (P = 0.084, OR 1.16, 95% CI 0.98–1.38). Large-volume hospitals had a significantly higher 1-month mortality rate (P = 0.0040, OR 1.10, 95% CI 1.03–1.18).ConclusionHospitals with increased RRS call rates had significantly decreased unplanned ICU admission in patients who had RRS activations. Patients who had RRS activations at large-volume hospitals had an increased 1-month mortality rate.     

Hospital mortality prognostication in sepsis using the new biomarkers suPAR and proADM in a single determination on ICU admission

Purpose

The soluble form of the urokinase-type plasminogen activator receptor (suPAR) and proadrenomedullin (proADM) are two new and promising sepsis biomarkers. We assessed the prognostic value of a single determination of proADM and suPAR, comparing them with C-reactive protein (CRP) and procalcitonin (PCT), and evaluating whether their addition to severity scores (APACHE II and SOFA) could improve their prognostic accuracy.

Methods

A single-centre prospective observational study conducted in an adult intensive care department at Marques de Valdecilla University Hospital in Spain. APACHE II and SOFA scores, CRP, PCT, suPAR and proADM levels on the day of ICU admission were collected.

Results

A total of 137 consecutive septic patients were studied. The best area under the curve (AUC) for the prediction of in-hospital mortality was for APACHE II (0.82) and SOFA (0.75) scores. The ROC curve for suPAR yielded an AUC of 0.67, higher than proADM (0.62), CRP (0.50) and PCT (0.44). Significant dose-response trends were found between hospital mortality and suPAR (OR Q4 = 4.83, 95 % CI 1.60–14.62) and pro-ADM (OR Q4 = 3.00, 95 % CI 1.06–8.46) quartiles. Non-significant associations were found for PCT and CRP. The combination of severity scores and each biomarker did not provide superior AUCs.

Conclusions

SuPAR and, to a lesser extent, proADM levels on ICU admission were better tools in prognosticating in-hospital mortality than CRP or PCT. However, neither of the two new biomarkers has been demonstrated to be excessively useful in the current setting. The prognostic accuracy was better for severity scores than for any of the biomarkers.     

Predictors of acute decompensation after admission in ED patients with sepsis

Purposes

The aim of the study was to identify predictors of acute decompensation within 48 hours of admission among infected emergency department (ED) patients admitted to a regular nursing floor.

Procedures

This used a case control study of infected ED patients admitted to a regular nursing floor and who received a discharge diagnosis of sepsis. A multivariate logistic regression model was constructed with the dependent variable as transfer to an intensive care unit (ICU) within 48 hours of admission.

Findings

Seventy-eight patients were enrolled—34 in the ICU group and 44 in the floor group. Only low bicarbonate (<20 mmol/L) (odds ratio [OR], 7.40; 95% confidence interval [CI], 2.35-23.30) and absence of fever (OR, 3.66; 95% CI, 1.11-12.60) were predictive of ICU transfer.

Conclusions

Among infected ED patients admitted to a regular floor, absence of fever and low bicarbonate were independently associated with ICU transfer within 48 hours. Particular attention should be paid to similar patients to ensure appropriate identification of severe infection and appropriate risk stratification.     

入重症监护室时血乳酸水平对脓毒症患者急性肾损伤发生的预测价值

目的 对前瞻性FINNAKI研究进行二次分析,探讨入重症监护室(ICU)时血乳酸水平对脓毒症患者12 h后急性肾损伤(AKI)发生的预测价值.方法 选取FINNAKI队列研究数据中刚入ICU时未合并AKI的409例脓毒症患者作为研究对象,采用血乳酸三分位数法将其分为低乳酸组、中乳酸组和高乳酸组,比较3组患者12 h后A...     

Sodium arsenite induces the stress response in the gut and decreases bacterial translocation in a burned mouse model with gut-derived sepsis

Bacteria translocation from the bowel to systemic organs after burn injury may contribute to or be a cause of sepsis and multiple organ failure. The stress response confers protection under stressful conditions that would otherwise lead to cell damage or death. We investigated whether prior induction of the stress response by sodium arsenite could affect bacterial translocation after thermal injury. HSP-70, a highly stress-inducible protein, was used as a marker for induction of the stress response. Balb/c mice were intravenously injected with 4 mg/kg of sodium arsenite and killed at selected times post-treatment. Other treated mice were then gavaged with 10(10) E. coil or 10(10) 111In-labeled E. coil followed by a 20% burn. Survival was observed for 10 days. Mice gavaged with radiolabeled E. coil were killed 4 h post-burn to determine the effect of HSP-70 induction on microbial translocation in mesenteric lymph nodes (MLN), liver, and spleen. Sodium arsenite-injected mice showed HSP-70 induction in the ileum that increased in a time-dependent manner with peak expression 12 h post-injection. Treated mice showed a significantly higher survival rate (93%) than controls (46%; P < 0.05), and detection of 111In-labeled E. coli was significantly less in the liver and spleen (P < 0.05). These data show that sodium arsenite induced HSP-70 expression in the small intestine. The stress response was associated with significantly increased survival and significant decrease in detection of 111In-labeled E. coil in the liver and spleen in a burned mouse model with gut-derived sepsis.     

Iatrogenic events contributing to ICU admission: a prospective study

Objective  

To determine the incidence, risk factors, severity, and preventability of iatrogenic events (IEs) as a cause of intensive care unit (ICU) admission.     

Adequate antibiotic therapy prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality

IntroductionIn patients with severe sepsis and septic shock as cause of Intensive Care Unit (ICU) admission, we analyze the impact on mortality of adequate antimicrobial therapy initiated before ICU admission.MethodsWe conducted a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock from January 2008 to September 2013. The primary end-point was in-hospital mortality. We considered two groups for comparisons: patients who received adequate antibiotic treatment before or after the admission to the ICU.ResultsA total of 926 septic patients were admitted to ICU, and 638 (68.8%) had available microbiological isolation: 444 (69.6%) received adequate empirical antimicrobial treatment prior to ICU and 194 (30.4%) after admission. Global hospital mortality in patients that received treatment before ICU admission, between 0-6h ICU, 6–12h ICU, 12–24h ICU and after 24 hours since ICU admission were 31.3, 53.2, 57.1, 50 and 50.8% (p<0.001). The multivariate analysis showed that urinary focus (odds ratio (OR) 0.20; 0.09–0.42; p<0.001) and adequate treatment prior to ICU admission (OR 0.37; 0.24–0.56; p<0.001) were protective factors whereas APACHE II score (OR 1.10; 1.07–1.14; p<0.001), septic shock (OR 2.47; 1.57–3.87; p<0.001), respiratory source (OR 1.91; 1.12–3.21; p=0.016), cirrhosis (OR 3.74; 1.60–8.76; p=0.002) and malignancy (OR 1.65; 1.02–2.70; p=0.042) were variables independently associated with in-hospital mortality. Adequate treatment prior to ICU was a protective factor for mortality in patients with severe sepsis (n=236) or in septic shock (n=402).ConclusionsThe administration of adequate antimicrobial therapy before ICU admission is decisive for the survival of patients with severe sepsis and septic shock. Our efforts should be directed to assure the correct administration antibiotics before ICU admission in patients with sepsis.     

Association between sepsis at ICU admission and mortality in patients with ICU-acquired pneumonia: An infectious second-hit model

PurposeWe explore the hypothesis that critically ill patients developing ICU-acquired pneumonia (ICU-AP) have worse outcomes and an altered inflammatory response if their ICU admission was sepsis-related.MethodsProspective cohort study in two centers. Patients with ICU-AP were evaluated according to their previous exposure to sepsis at ICU-admission. Demographic variables, comorbidities, severity scores at admission and at the time of acquisition of ICU-AP, and serum biomarkers of the inflammatory response were evaluated. Primary outcome: 90-day mortality. Secondary outcomes: ICU and hospital length of stay, mortality at days 28 and 180, in-hospital mortality, ventilator-free days (day-28), and inflammatory response. Propensity scoring weighted the risk of previously-acquired sepsis. Multivariate analysis evaluated the risk of mortality by day-90. Sensitivity analyses evaluated the primary outcome in different subgroups.ResultsOf 341 patients enrolled, 147 had sepsis on ICU-admission. Adjusted risk of mortality at 90 days did not differ overall [hazard ratio (HR) = 0.94(CI:0.65–1.37)], nor in subpopulations with a confirmed etiology of pneumonia [HR = 0.93(CI:0.57–1.53)] or sepsis [HR = 0.91(0.54–1.55)], ventilator-associated pneumonia (VAP) [HR = 1.01(CI:0.61–1.68)], nor non-VAP ICU-AP [HR = 0.83(CI:0.40–1.71)]. No differences were found in clinical secondary outcomes, the inflammatory response was similar.ConclusionsPrevious sepsis does not appear to predispose to higher mortality nor worse outcomes in patients who develop ICU-acquired pneumonia.     

综合ICU患者入室前及转出后访视内容标准的构建

目的 构建综合ICU患者入室前及转出后访视内容标准。 方法 采用循证护理、质性研究方法筛选标准指标池,通过专家会议编制原始问卷;采用两轮德尔菲法对30名专家进行函询。 结果 通过两轮专家函询,最终形成5项一级指标、21项二级指标和81项三级指标。两轮专家函询的权威程度为0.82、0.85,协调系数为0.31~0.44。 结论 综合ICU患者入室前及转出后访视内容标准专家意见趋于一致,专家积极性和权威性较高,能够指导综合ICU护士访视实践。     

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

ObjectivesEarly 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.DesignRetrospective analysis of a prospective multicenter dataset. Early admission was defined as admission in the ICU < 24 h of hospital admission. We assessed the association between early ICU admission and hospital mortality in CICP via survival analysis and propensity score matching.ResultsOf 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.ConclusionIn 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.     

3种指标联合检测对ICU脓毒症患者早期诊断的应用研究

目的探讨联合检测血清降钙素原(PCT)、白细胞介素-6(IL-6)和C反应蛋白(CRP)在重症监护病房(ICU)脓毒症患者早期诊断中的应用。方法选择ICU病区明确诊断的早期脓毒症患者89例(脓毒症组),发热高峰期且未使用抗菌药物时,采血送血培养并检测PCT、IL-6、CRP水平,同时选择同时期来本院健康体检者132例(健康对照组),采血检测PCT、IL-6、CRP水平。PCT、IL-6的检测为电化学发光法,CRP的检测为免疫透射比浊法。结果 ICU脓毒症患者PCT、IL-6、CRP检测值明显高于健康对照组,且差异具有统计学意义(P0.01);联合检测的敏感性和特异性明显高于单独检测,PCT+IL-6、PCT+CRP、PCT+IL-6+CRP 3种联合检测组合的敏感性分别为91.3%、90.5%和91.9%,特异性分别为89.5%、88.3%和89.4%,准确度分别为85.5%、85.3%和85.6%。结论联合检测PCT+IL-6+CRP、PCT+IL-6或PCT+CRP,有助于临床识别早期脓毒症。     

The need for ICU admission in intoxicated patients: a prediction model

Context: Intoxicated patients are frequently admitted from the emergency room to the ICU for observational reasons. The question is whether these admissions are indeed necessary.

Objective: The aim of this study was to develop a model that predicts the need of ICU treatment (receiving mechanical ventilation and/or vasopressors <24?h of the ICU admission and/or in-hospital mortality).

Materials and methods: We performed a retrospective cohort study from a national ICU-registry, including 86 Dutch ICUs. We aimed to include only observational admissions and therefore excluded admissions with treatment, at the start of the admission that can only be applied on the ICU (mechanical ventilation or CPR before admission). First, a generalized linear mixed-effects model with binominal link function and a random intercept per hospital was developed, based on covariates available in the first hour of ICU admission. Second, the selected covariates were used to develop a prediction model based on a practical point system. To determine the performance of the prediction model, the sensitivity, specificity, positive, and negative predictive value of several cut-off points based on the assigned number of points were assessed.

Results: 9679 admissions between January 2010 until January 2015 were included for analysis. In total, 632 (6.5%) of the patients admitted to the ICU eventually turned out to actually need ICU treatment. The strongest predictors for ICU treatment were respiratory insufficiency, age >55 and a GCS <6. Alcohol and “other poisonings” (e.g., carbonmonoxide, arsenic, cyanide) as intoxication type and a systolic blood pressure ≥130?mmHg were indicators that ICU treatment was likely unnecessary. The prediction model had high sensitivity (93.4%) and a high negative predictive value (98.7%).

Discussion and conclusion: Clinical use of the prediction model, with a high negative predictive value (98.7%), would result in 34.3% less observational admissions.     

Rehabilitation outcomes after infection-related spinal cord disease: a retrospective analysis

OBJECTIVES: To compare injury characteristics, demographics, and functional outcomes of patients with infection-related spinal cord disease (IR-SCD) vs. those with traumatic spinal cord injury (SCI). DESIGN: A 10-yr retrospective review of 34 consecutive patients with IR-SCD admitted to an SCI rehabilitation unit at a Level 1 tertiary university medical center. Outcome measures included length of stay (LOS), FIM motor scores, and home discharge rates. RESULTS: The cause of IR-SCD was most often spinal epidural abscess secondary to Staphylococcus aureus (74%). Weakness (90%) and neck/back pain (84%) were the most frequent initial admitting symptoms. Identifiable risk factors included history of recent infection (42%), diabetes mellitus (32%), and intravenous drug abuse (26%). SCD-related complications most commonly included pain (81%), urinary tract infection (52%), and spasticity (45%). When compared with traumatic SCI (n = 560), patients with IR-SCD comprised significantly less of the SCI/D rehabilitation admissions (3% vs. 61%), were older (53 vs. 40 yrs), and more often female (35% vs. 16%). Injuries were more commonly located in the thoracic region (48% vs. 38%). Patients with IR-SCD more often had incomplete injuries (94% vs. 57%). Thirty-two percent of IR-SCD patients had improvements in AIS impairment scale classification. LOS was longer on acute care (25 vs. 16 days), but similar on rehabilitation (36 vs. 34 days), and with lower FIM motor changes (16.2 vs. 22.8) during rehabilitation. Patients with IR-SCD were less often discharged to home (56% vs. 75%). CONCLUSIONS: Patients with infection-related SCD comprise a significant subset of SCI/D rehabilitation admissions and have differing demographic and injury characteristics compared with traumatic SCI. Despite less-severe injury characteristics and similar rehabilitation LOS, they achieve lower functional improvements and are less often discharged home, underscoring the importance of patient/family education and discharge planning.