Efficacy of continuous regional arterial infusion of a protease inhibitor and antibiotic for severe acute pancreatitis in patients admitted to an intensive care unit

To investigate the efficacy of continuous regional arterial infusion (CRAI) of a protease inhibitor and antibiotic for severe acute pancreatitis (SAP) in patients admitted to an intensive care unit (ICU). A total of 51 patients with SAP requiring admission to an ICU were studied. The patients were divided into two groups: one received the protease inhibitor nafamostat mesylate and the antibiotic imipenem by continuous regional arterial infusion (CRAI group) and the other received protease inhibitors and antibiotics by intravenous infusion (non-CRAI group). To evaluate the therapeutic usefulness of CRAI of a protease inhibitor and antibiotic for SAP, the rate of surgery and the cumulative survival rate were compared between the non-CRAI group and the CRAI group. The rate of surgery was 32% in the non-CRAI group and 9% in the CRAI group (P = 0.08). Cumulative survival rates at 1, 6, and 12 months were 77.9%, 48.9%, and 48.9% in the non-CRAI group compared with 100.0%, 100.0%, and 87.1% in the CRAI group. Outcome was thus significantly better in the CRAI group than in the non-CRAI group (P = 0.002). CRAI of a protease inhibitor and antibiotic may decrease the need for surgical therapy and reduce mortality in patients with SAP.     

Hormonal modifications in patients admitted to an internal intensive care unit for acute hypoxaemic respiratory failure

To clarify which endocrine modifications can be observed in acute hypoxaemic respiratory failure, 15 severely ill male patients [PAT; median age: 61 (range: 48 years); median height: 173 (range: 12) cm; median mass: 73 (range 31) kg] were investigated immediately upon admission to an intensive care unit (ICU) for this clinical disorder. Before starting treatment, the blood gases were measured and a number of selected hormones with special relevance for an ICU setting were determined. These are known to be modified by acute hypoxaemia in healthy subjects and to possess glucoregulatory properties, or an influence upon cardiocirculation or the vascular volume regulation: insulin, cortisol, adrenaline, noradrenaline, atrial natriuretic peptide, renin, aldosterone, angiotensin converting enzyme, and endothelin-I (ET). To elucidate whether potential endocrine changes resulted from acute hypoxaemia alone, the underlying disease, or unspecific influences connected with the ICU setting, all measurements were compared to those of a completely healthy reference group (REF) with comparable acute experimental hypoxaemia. The latter state was achieved by having the REF breathe a gas mixture with the oxygen content reduced to 14% (H).In the REF, neither the medians nor the distribution of endocrinologic measurements were modified significantly by acute hypoxaemia. In the PAT, the medians were increased considerably, yet with a slight diminution of ET. The distribution of individual values was considerably broader than in the REF with H.In conclusion, considerable increases in the means of the above hormones, with the exception of ET, can be registered in severely ill patients admitted to ICUs with acute hypoxaemic failure. However, such modifications cannot be considered attributable exclusively to acute arterial hypoxaemia. The underlying clinical disorders, such as septicaemia or an unspecific endocrine epiphenomenon, including severe and not only hypoxaemic stress, seem to be predominant.     

Prognostic factors associated with six month mortality of critically ill elderly patients admitted to the intensive care unit with severe acute cholangitis

BackgroundLittle is known about the outcomes of elderly patients admitted to the intensive care unit (ICU) with severe acute cholangitis (SAC). The objectives were to describe the 6-month mortality in patients with SAC ≥75 years and to identify factors associated with this mortality.MethodsBi-center retrospective study of critically ill elderly patients with SAC conducted between 2013 and 2017. Demographic and clinical variables of ICU and hospital stays with a 6-month follow-up were analyzed.Results85 patients, with a median [Q1–Q3] age of 83 [80–89] years were enrolled of whom 51 (60%) were men. SAC was due to choledocholithiasis in 72 (85%) patients. Median [Q1–Q3] ICU length of stay was 3 [2–6] days. Median [Q1–Q3] admission SAPS II was 50 [42–70]. The ICU and 6-month mortality rates were 18% and 48% respectively. Multivariate analysis showed that malnutrition (OR = 34.5, 95% CI [1.4–817.9]) and a decrease in SOFA score at 48 h (OR by unit 0.7, 95% CI [0.5–0.9]) were associated with higher 6-month mortality.ConclusionIn their decision-making process, ICU physicians and hepato-pancreato-biliary surgeons could use these data to estimate the probability of survival of an elderly patient presenting with SAC and to offer time-limited trials of intensive care.Trial registrationNCT03831529.     

Prognosis of patients with acute myeloid leukaemia admitted to intensive care

This retrospective study assessed the prognostic factors associated with early and long-term outcome in consecutive patients with acute myeloid leukaemia (AML) admitted to the intensive care unit (ICU) over a 9-year period. A total of 83 patients were studied (age 48 +/- 16 years), among whom 60% were neutropenic on admission. For 68%, admission occurred within the first month following diagnosis of AML. The main reason for ICU admission was an acute respiratory disease in 82% of cases. Mechanical ventilation (MV) was required in 57% of patients. In-ICU mortality was 34%. Among patients discharged alive from ICU, 49% died within a year after discharge. Factors significantly associated with in-ICU death in multivariate analysis were simplified acute physiology score II and need for invasive MV (IMV). Age, performance status, AML3 subtype and complete remission were significantly associated with 1-year survival. Patients with acute respiratory failure initially supported with non-invasive MV had significantly better ICU outcome than patients initially supported with IMV. In conclusion, ICU admission is justified for selected patients with AML. The ICU mortality rate is highly predictable by the acute illness severity score. A 1-year survival is predicted by haematological prognostic factors.     

Outcome predictors of cirrhosis patients admitted to the intensive care unit

OBJECTIVE: To evaluate outcome predictors of patients with cirrhosis admitted to an intensive care unit (ICU). METHODS: One hundred and twenty-nine consecutive patients with cirrhosis admitted to the ICU at a tertiary care transplant centre in Saudi Arabia between March 1999 and December 2000 were entered prospectively in an ICU database. Liver transplantation patients and readmissions to the ICU were excluded. The following data were documented: demographic features, severity of illness measures, parameters of organ failure, presence of gastrointestinal bleeding, and sepsis. The need for mechanical ventilation, renal replacement therapy and pulmonary artery catheter placement was recorded. The primary endpoint was hospital outcome. RESULTS: Cirrhotic patients admitted to the ICU had high hospital mortality (73.6%). However, the actual mortality was not significantly different from the predicted mortality using prediction systems. There was an association between the number of organs failing and mortality. Coma and acute renal failure emerged as independent predictors of mortality. All patients who were monitored with pulmonary artery catheterisation in this study died. Patients requiring mechanical ventilation and renal replacement therapy had very high mortalities (84% and 89%, respectively). All 13 cirrhotic patients admitted to ICU immediately post-cardiac arrest in this study died. CONCLUSIONS: Cirrhotic patients admitted to ICU have a poor prognosis, especially when admitted with coma, acute renal failure or post-cardiac arrest. The consistently poor prognosis associated with certain ICU interventions should raise new awareness regarding limitations of medical therapy. These mortality statistics compel a critical re-examination of uniformly aggressive life support for the critically ill cirrhotic patient, a percentage of whom will not benefit from invasive measures.     

Outcome of patients having dermatomyositis admitted to the intensive care unit

Patients having systemic rheumatic diseases constitute a small percentage of admissions to the medical intensive care units (ICUs). Dermatomyositis (DM) is one of the rheumatic diseases that have secondary complications that may lead to a critical illness requiring hospitalization in the ICU. Herein, we present the features, clinical course, and outcome of critically ill patients having DM who were admitted to the ICU. The medical records of six DM patients admitted to the ICU in a large tertiary hospital in a 12-year period were reviewed. The mean age of patients at time of admission to the ICU was 38 (range 16–37). Mean disease duration from diagnosis to admission to the ICU was 1.6 years (range 1 month–8 years), while the main reason for admission to the ICU was acute respiratory failure. Two of six patients died during the hospitalization. The main causes of death were respiratory complications and sepsis. The outcome of DM patients admitted to the ICU was generally not different from the outcome of other patients hospitalized in the ICU. The main reason for hospitalization was acute respiratory failure. As there are many reasons for respiratory failure in DM, an early diagnosis and aggressive appropriate treatment may help to further reduce the mortality in these patients.     

Ineffectiveness of routine abdominal radiography in patients with gastrointestinal hemorrhage admitted to an intensive care unit

GOALS: To determine the utility of plain abdominal radiography in the initial evaluation of acute gastrointestinal (GI) hemorrhage in a medical intensive care unit. BACKGROUND: Plain abdominal radiographs are frequently used in the routine evaluation of patients with GI bleeding. The utility of these studies in the intensive care unit setting is unclear. STUDY: The study was a retrospective chart review of 71 adult subjects admitted to a medical intensive care unit with the diagnosis of GI bleeding. Subjects were excluded if they presented with peritoneal signs, received an abdominal CT scan in the 24 hours prior to admission, or were chronically treated with immunosuppressive medication. Subjects were divided into two cohorts based on whether or not they underwent plain abdominal radiography during the first hospital day. The primary study endpoints were hospital mortality, intensive care unit length of stay, and whether or not radiographic findings altered clinical management. RESULTS: Of the 71 patients admitted with a diagnosis of GI bleeding (mean age 65.8 +/- 14.5 years, 73.2% male), 56 (79%) had a plain abdominal radiograph performed. Subjects who had a plain film did not differ significantly from those who did not in age, gender, degree of anemia, degree of coagulopathy, or in severity of illness as measured by Acute Physiology and Chronic Health Evaluation (APACHE II) score. There was no statistically significant difference in hospital mortality or intensive care unit length of stay between patients who received plain films and those who did not. In no subject (0%; 95% confidence interval, 0%-5.4%) did abdominal radiography reveal an abnormality that altered clinical management. CONCLUSIONS: Based on our observations, plain films of the abdomen do not appear to alter clinical outcomes or management decisions for patients with GI bleeding and normal abdominal examinations who are admitted to the intensive care unit.     

Outcome of patients with idiopathic pulmonary fibrosis admitted to the intensive care unit

This retrospective study describes the clinical course of 38 patients with idiopathic pulmonary fibrosis (IPF) admitted to the intensive care unit (ICU). There were 25 males and 13 females who were the mean age of 68.3 +/- 11.5 years. Twenty patients were on corticosteroids at the time of admission to the hospital, and 24 had been on home oxygen therapy. The most common reason for ICU admission was respiratory failure. The Acute Physiology and Chronic Health Evaluation III-predicted ICU and hospital mortality rates were 12% and 26%, whereas the actual ICU and hospital mortality rates were 45% and 61%, respectively. We did not find significant differences in pulmonary function or echocardiogram findings between survivors and nonsurvivors. Mechanical ventilation was used in 19 patients (50%). Sepsis developed in nine patients. Multiple organ failure developed in 14% of the survivors and in 43% of the nonsurvivors (p = 0.14). Ninety-two percent of the hospital survivors died at a median of 2 months after discharge. These findings suggest that patients with IPF admitted to the ICU have poor short- and long-term prognosis. Patients with IPF and their families should be informed about the overall outlook when they make decisions about life support and ICU care.     

Hospital survival of older patients admitted to a medical intensive care unit

BACKGROUND AND AIMS: It is not well-known whether age or the severity of underlying conditions affects mortality in critically ill patients. The aim of this study was therefore to determine whether age is an independent predictor of hospital survival for critically ill patients. METHODS: Patients consecutively admitted to the intensive care unit from December 1 1999 to July 31 2001 were included in the study. Patients were stratified into 3 groups (< or = 65 years old, 66-75 years old, > 75 years old) and were compared, by both bivariate and multivariate analyses, to ascertain whether older critically ill patients had poorer hospital survival than younger patients. RESULTS: Of 331 patients, 178 (53.8%) patients were < or = 65 years old, 100 (30.2%) were 66-75 years old, and 53 (16%) were > 75 years old. Multivariate logistic regression analysis revealed that older age, presence of fatal comorbidities, mechanical ventilation, central venous catheterization, and higher acute physiology and chronic health evaluation score II (excluding the score obtained from age) were independent predictors of hospital mortality in the study population. Kaplan-Meier survival analysis revealed that patients < or = 65 years old had better hospital survival than older patients (p=0.02). CONCLUSIONS: Older critically ill patients have poorer hospital survival than patients < or = 65 years old, when other confounding factors such as disease severity score, invasive procedures and comorbidities were controlled for.     

Determinants of outcome in elderly patients admitted to the intensive care unit

BACKGROUND: Age is thought to be strongly associated with intensive care outcomes, but this relationship may be confounded by many clinical variables. OBJECTIVES: To compare clinical characteristics of elderly patients (> or = 65 years) admitted to the intensive care unit (ICU) with those in younger patients and to identify the risk factors which independently could predict mortality in patients aged > or = 75 years. DESIGN: Prospective observational cohort study. SETTING: Medical-surgical ICU in a university hospital. SUBJECTS: 2,067 adult patients admitted to the ICU. METHODS: Comparison of clinical characteristics of patients divided into groups according to their age. RESULTS: Elderly patients comprised 51% of the study population. Compared with younger patients, elderly patients were more severely ill on admission, had shock and renal dysfunction. The presence of infection on admission and the incidence rate of infection acquired during stay in the ICU also significantly increased with age. Hospital mortality increased with age: for patients aged > or = 75 years, it was more than double that of patients aged <65 years (39% versus 19%, P < 0.001). Using multivariate logistic regression analysis we determined the independent risk factors of hospital mortality for the patients aged > or = 75 years: impaired level of consciousness, infection on admission, ICU-acquired infection and severity of illness score. CONCLUSIONS: Morbidity and mortality in elderly patients admitted to the ICU are higher than in younger patients. The most important factors independently associated with the highest risk of death are the severity of illness, impaired level of consciousness and infection.     

Predictors of outcome in patients with hematologic malignancies admitted to the intensive care unit

Purpose

Several studies showed conflicting results about prognosis and predictors of outcome of critically ill patients with hematological malignancies (HM). The aim of this study is to determine the hospital outcome of critically ill patients with HM and the factors predicting the outcome.

Analysis of patients with acute exogenous poisoning at an intensive care unit

Over a period of 2 years patients with exogenic intoxications take 16% in the total number of patients of the department for internal intensive care. The cases in question were 43.3% males and 56.7% females. The average age of the patients with 31 years was low. The mortality was 2.4%. In the first place of the exogenic intoxications were intoxications with the groups of medicaments sedatives, hypnotics, tranquilizers, analgetics and antipyretics followed by intoxications with neuroleptics, beta-receptor blockers, antidepressives, antiepileptics and glycosides. The rate of complications was greatest in the mixed intoxications.     

Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage

BACKGROUND: Esophagogastroduodenoscopy (EGD) is generally indicated for the management of patients admitted to intensive care units (ICUs) with upper gastrointestinal (GI) hemorrhage but its impact in community practice has not been measured. Thus, the effectiveness of 3 EGD factors, viz., accurate initial diagnosis, performance within 24 hours of admission (early EGD), and appropriate intervention, was examined. METHODS: Records of 214 patients admitted to the ICU of 10 metropolitan hospitals with upper GI hemorrhage were reviewed. Unadjusted and severity-adjusted associations of the 3 EGD factors with length of hospital stay, length of ICU stay, readmission to ICU, recurrent bleeding, surgery, and death were evaluated. RESULTS: Inaccurate diagnosis occurred in 10% of patients at initial EGD and was associated with significant increases in risk of recurrent bleeding (70% vs. 11%, p < 0.001), rate of surgery (20% vs. 4%, p < 0.05), length of hospital stay (median 7.5 vs. 5 days, p < 0.005), length of ICU stay (median 4 vs. 2 days, p < 0.005), and rate of readmission to ICU (20% vs. 0.6%, p < 0.001). These associations persisted after adjusting for severity of illness. Early EGD performed in 82% of patients was associated with significant severity-adjusted reductions in hospital (-33%: 95% CI [-45%, -18%]) and ICU (-20%: 95% CI [-24%, -3%]) stay. Appropriate intervention at initial EGD, performed in 84% of patients, was associated with reductions in severity-adjusted length of ICU stay (-18%: 95% CI [-32%, 0%]) and rate of recurrent bleeding (odds ratio = 0.37, 95% CI [0.13, 1.06]). CONCLUSIONS: Early, accurate EGD with appropriate therapeutic intervention is effective as practiced in the community and is associated with improved outcomes for patients with upper GI hemorrhage admitted to the ICU. Inaccurate diagnosis at initial EGD is uncommon but has a significant adverse association with all outcome measures.