Complications of care in a medical intensive care unit

Objective:To determine the frequency and nature of complications of care in the medical intensive care unit (MICU). Design:Prospective, observational study. Setting:Seven-bed MICU in a teaching and referral VA hospital. Patients:295 consecutive patients admitted to the MICU during a ten-month study period. Interventions:None. Measurements and main results:Forty-two patients (14%, 95% confidence interval 13%, 16%) experienced one or more complications during their MICU stays. Compared with other MICU patients, those experiencing complications tended to be older (mean age ± SD: 63.6±10.1 years vs 59.3±14.0 years, p<0.02) and more acutely ill (mean Acute Physiology Score ± SD: 18.3±8.0 vs 12.5±8.0, p=0.0001). These patients also had significantly longer MICU lengths of stay (mean ± SD: 12.3±14.7 days vs 3.1±4 days, p<0.0001) and higher hospital mortality rates (67% vs 27%, p<0.001). The 67% mortality rate among patients with complications significantly exceeded the expected mortality rate of 46% (calculated from the APACHE risk equation). Conclusion:Complications of care in the MICU are not rare and may independently contribute to in-hospital mortality. The potential for complications must be recognized when considering ICU care.     

Fundamental and intensive care of acute pancreatitis

Patients who have been diagnosed as having acute pancreatitis should be, on principle, hospitalized. Crucial fundamental management is required soon after a diagnosis of acute pancreatitis has been made and includes monitoring of the conscious state, the respiratory and cardiovascular system, the urinary output, adequate fluid replacement and pain control. Along with such management, etiologic diagnosis and severity assessment should be conducted. Patients with a diagnosis of severe acute pancreatitis should be transferred to a medical facility where intensive respiratory and cardiovascular management as well as interventional treatment, blood purification therapy and nutritional support are available. The disease condition in acute pancreatitis changes every moment and even symptoms that are mild at the time of diagnosis may become severe later. Therefore, severity assessment should be conducted repeatedly at least within 48 h following diagnosis. An adequate dose of fluid replacement is essential to stabilize cardiovascular dynamics and the dose should be adjusted while assessing circulatory dynamics constantly. A large dose of fluid replacement is usually required in patients with severe acute pancreatitis. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with severe acute pancreatitis. Although the efficacy of intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional continuous regional arterial infusion and blood purification therapy.     

Audit of patients with severe acute pancreatitis admitted to an intensive care unit

Background

Severe acute pancreatitis (SAP) is a disease with high morbidity and mortality. We undertook a study of patients with SAP admitted to the intensive care unit (ICU) of a tertiary referral hospital.

Methods

Between 2002 and 2007, 50 patients with SAP were admitted in our intensive care unit (ICU). Data were collected from their medical records and their clinical profile, course and outcome were retrospectively analyzed. Patients were categorized into survivor and nonsurvivor groups, and were further classified based on interventions such as percutaneous drainage and surgical necrosectomy.

Results

SAP contributed 5?% of total ICU admissions during the study period. Median age of survivors (n?=?20) was 34 against 44?years in nonsurvivors (n?=?30). Median Acute Physiology and Chronic Health Evaluation (APACHE) II score in nonsurvivors was 16.5 (8?C32) vs. 12.5 (5?C20) in survivors (p?=?0.002). Patients with APACHE II score ??12 had mortality >80?% compared to 23?% with score <12 (p?<?0.001). Median Sequential Organ Failure Assessment (SOFA) scores on admission and on days 3, 7, 14, and 21 were significantly higher in nonsurvivors compared to survivors (p?<?0.05). Mean (SD) intraabdominal pressure was 23 (3.37) mmHg in nonsurvivors vs. 19.05 (2.51) in survivors (p?<?0.05). Patients with renal failure had significant mortality (p?<?0.001). Length of ICU stay, requirement for vasopressor, total parenteral nutrition, and the amount of blood and blood product transfusions differed significantly between patients with and without intervention.

Conclusions

APACHE II and SOFA scores and other clinical data correlated with outcome in SAP admitted to ICU.     

ICU内慢性阻塞性肺疾病急性加重患者预后危险因素分析

目的筛选与ICU内AECOPD患者死亡相关的独立危险因素。方法这是一项回顾性病例对照研究,回顾性分析2016年1月1日-2019年5月30日入住广州医科大学附属第一医院ICU的AECOPD患者,根据出ICU时的转归分为存活组和死亡组。收集患者的人口学、临床资料、治疗转归。经多元Logistics回归分析患者死亡的独立危险因素,受试者操作特性(ROC)曲线分析独立危险因素对AECOPD患者死亡的预测价值。结果共纳入170例AECOPD患者,单因素分析发现高APACHEⅡ评分,高中性粒细胞比例、降钙素原、肌钙蛋白I、pro-BNP、乳酸、尿素氮浓度,低血清白蛋白和总蛋白水平以及合并脓毒症休克是AECOPD患者ICU内死亡的危险因素(P值均<0.05)。经Logistics回归分析,筛选出死亡的独立危险因素为高APACHEⅡ评分、合并脓毒症休克,OR值分别为1.13(95%CI 1.052~1.214)、5.092(95%CI 1.697~15.277),血清总蛋白水平是死亡的保护因素,OR值为0.879(95%CI 0.818~0.944)。ROC曲线显示联合APACHEⅡ评分、血清总蛋白水平、是否合并脓毒症休克三个指标的模型显示出对患者死亡有较高的预测价值,ROC曲线下面积(AUC)为0.848(95%CI 0.785~0.911;P<0.0001)。结论入住ICU的AECOPD患者有高APACHEⅡ评分,低总蛋白水平,合并脓毒症休克的预后较差。     

Effects of acute kidney injury on acute pancreatitis patients’ survival rate in intensive care unit: A retrospective study

BACKGROUNDAcute kidney injury (AKI) is one of the most common acute pancreatitis (AP)-associated complications that has a significant effect on AP, but the factors affecting the AP patients’ survival rate remains unclear.AIMTo assess the influences of AKI on the survival rate in AP patients. METHODSA total of 139 AP patients were included in this retrospective study. Patients were divided into AKI group (n = 72) and non-AKI group (n = 67) according to the occurrence of AKI. Data were collected from medical records of hospitalized patients. Then, these data were compared between the two groups and further analysis was performed.RESULTSAKI is more likely to occur in male AP patients (P = 0.009). AP patients in AKI group exhibited a significantly higher acute physiologic assessment and chronic health evaluation II score, higher Sequential Organ Failure Assessment score, lower Glasgow Coma Scale score, and higher demand for mechanical ventilation, infusion of vasopressors, and renal replacement therapy than AP patients in non-AKI group (P < 0.01, P < 0.01, P = 0.01, P = 0.001, P < 0.01, P < 0.01, respectively). Significant differences were noted in dose of norepinephrine and adrenaline, duration of mechanical ventilation, maximum and mean values of intra-peritoneal pressure (IPP), maximum and mean values of procalcitonin, maximum and mean serum levels of creatinine, minimum platelet count, and length of hospitalization. Among AP patients with AKI, the survival rate of surgical intensive care unit and in-hospital were only 23% and 21% of the corresponding rates in AP patients without AKI, respectively. The factors that influenced the AP patients’ survival rate included body mass index (BMI), mean values of IPP, minimum platelet count, and hospital day, of which mean values of IPP showed the greatest impact.CONCLUSIONAP patients with AKI had a lower survival rate and worse relevant clinical outcomes than AP patients without AKI, which necessitates further attention to AP patients with AKI in surgical intensive care unit.     

Management and prognosis of acute myocardial infarct in advanced age: comparison of the cardiac intensive care unit and the cardiology ward]

The aim of this prospective study was to assess the prognostic and most suitable management of AMI in elderly patients (age > or = 75 years). From September 1988 to August 1991, 129 such patients (pts) were evaluated: 35 (27%) were admitted to CCU because of arrhythmias or severe hemodynamic complications; 94 (73%) were addressed, according to bed availability, to CCU (55 pts) or Cardiology Ward (39 pts), where all patients underwent continuous ECG monitoring for at least 72 hours. Age, gender, history of previous angina or myocardial infarction, presence of chest pain or ECG ischemia on admission, site and extent of AMI, delay on admission, CPK-MB peak, recurrent angina, arrhythmias, heart failure, emotional disorders, hospital mortality and length of hospital stay were compared. Our results show that elderly patients who suffered from complicated AMI were at high risk for death and severe in-hospital complications. No significant prognostic differences were observed between the two groups with uncomplicated AMI. Thus hospitalization in the Cardiology Ward seems to be valuable, safe and well tolerated in our population of elderly patients with AMI, and without initial complications.     

Complications of bile-duct stones: acute cholangitis and pancreatitis

Acute cholangitis and pancreatitis are the most serious complications of gallstones. In particular, the incidence of acute pancreatitis has increased markedly in recent years. We here discuss the clinical features, laboratory and radiological examinations, and treatment for both conditions. Broad-spectrum antibiotics and biliary decompression (preferably by endoscopic means) are essential in cholangitis. In unstable patients, initial stent or nasobiliary drainage is preferred, with stone removal at a later stage.Patients with small gallstones and sludge are particularly at risk for acute pancreatitis. In most cases, diagnosis of gallstone pancreatitis is easily made. In some cases, however, the underlying cause is not evident (acute ‘idiopathic’ pancreatitis). The state-of-the-art diagnostic approach then includes magnetic resonance cholangio-pancreaticography (MRCP), endoscopic ultrasound, and possibly bile collection for microscopic examination for cholesterol crystals, and sphincter of Oddi manometry. Supportive therapy suffices in most gallstone patients with pancreatitis. Although enteral feeding should be instituted early in the case of a prolonged course, the concept of jejunal feeding to avoid pancreatic stimulation has recently been challenged. Antibiotic prophylaxis to prevent infection in patients with an expected severe course has become increasingly controversial. Four randomised controlled studies have evaluated the role of endoscopic retrograde cholangiography (ERCP) with papillotomy in gallstone pancreatitis. Early ERCP appears especially to benefit patients with significant bile-duct obstruction and (imminent) cholangitis. Circumstantial evidence supports ERCP in patients with expected severe pancreatitis but without significant bile-duct obstruction or cholangitis. Elective cholecystectomy is indicated after resolution of the complication, except where there are significant contraindications to surgery.

• endoscopic drainage is the preferred procedure for biliary decompression in acute cholangitis

• ERCP should be performed in acute biliary pancreatitis patients with significant biliary obstruction and/or (imminent) cholangitis; circumstantial evidence supports ERCP in patients with predicted severe pancreatitis but without significant biliary obstruction or cholangitis

• there is no convincing evidence for routine antibiotic prophylaxis in patients with predicted severe pancreatitis but without significant biliary obstruction or cholangitis

• detailed controlled studies are necessary to evaluate the role of nasojejunal versus nasogastric feeding in acute pancreatitis

• the role of probiotics in preventing infection of pancreatic necrosis in acute pancreatitis needs to be further defined

脓毒症合并急性肾损伤的危险因素及预后分析

目的:观察急诊重症监护室(EICU)脓毒症合并急性肾损伤(AKI)患者的临床特征并分析AKI发生的危险因素及预后。方法:纳入245例脓毒症患者,分为AKI组与非AKI组,比较2组的临床特征及实验室指标。AKI患者依据KDIGO诊断标准进行分级并进行生存分析。结果:245例脓毒症患者中161例发生了AKI,发生率为65.7%。其中,84例(52.2%)AKI患者死亡。多元回归分析显示,年龄、序贯器官衰竭评分(SOFA)、利尿剂使用、脓毒症分级是脓毒症患者并发AKI的独立危险因素。年龄、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)评分和AKI分级是脓毒症并发AKI患者28d死亡的危险因素。结论:EICU中脓毒症合并AKI的发生率和死亡率均较高,AKI的发生及预后与多种因素有关。     

Severe acute pancreatitis: prognosis and treatment implications

Severe acute pancreatitis (SAP) is a very important cause of morbi-mortality inside the context of gastrointestinal diseases, and there is still some controversy in important points regarding its medical and surgical management. The present review article assesses and compares the results and conclusions of several clinical trials with respect the staging of severity, supportive measurements, prophylactic antibiotics, surgical treatment of infected and sterile necrosis and the implications that such studies have in the prognosis and management of SAP. Endoscopic techniques of treatment are beyond the scope in this review.     

One-year incidence of hyperosmolar states and prognosis in a geriatric acute care unit

BACKGROUND: Hyperosmolar syndromes are associated with high mortality rates, yet little is known about their incidence and their prognosis. OBJECTIVE: To determine the 1-year incidence of hyperosmolar states and the prognostic factors for in-hospital and 1-year mortality. METHOD: A 6-month prospective cohort study was conducted in a 40-bed acute care geriatric unit and included all patients who developed plasma osmolarity of 320 mosm/l or greater. Age, sex and known cognitive impairment as possible risk factors of hyperosmolarity were assessed. In-hospital and 1-year mortality were calculated and risk factors for death among baseline patient characteristics were sought. RESULTS: 48 (11) of the 436 inpatients in the study were identified as hyperosmolar. Diabetic hyperosmolarity was found in 8 patients. Cognitive impairment was a risk factor for hyperosmolarity (relative risk 2.39, 95% confidence interval 2.18-3.33, p < 0.001), but not age or sex. Infections were accompanied by hyperosmolarity in 30 (62.5). Thirty-five patients (72.9) were bed- or chair-ridden. In-hospital mortality was higher in hyperosmolar patients (35.4) than in the others (16.7%, p = 0.003). Causes of death were infection in 5 (29.4), terminal cachexia in 5, thrombosis in 3, gastric bleeding in 1, renal failure in 2 and heart failure in 1. Functional dependency for mobility was a risk factor for in-hospital mortality but not the degree of hyperosmolarity. One-year mortality was 68.7%. Functional dependency and pressure ulcers were independent predictors of 1-year mortality (p = 0.005 and p = 0.044, respectively). CONCLUSION: Hyperosmolar states occurred in cognitively impaired and dependent patients and resulted in high mortality rates at short and at mid-term. Mortality was related to functional dependency rather than to hyperosmolarity.     

SARS in the intensive care unit

Approximately 20% of patients with severe acute respiratory syndrome (SARS) develop respiratory failure that requires admission to an intensive care unit (ICU). Old age, comorbidity, and elevated lactate dehydrogenase on hospital admission are associated with increased risk for ICU admission. ICU admission usually is late and occurs 8 to 10 days after symptom onset. Acute respiratory distress syndrome occurs in almost all admitted patients and most require mechanical ventilation. ICU admission is associated with significant morbidity, particularly an apparent increase in the incidence of barotrauma and nosocomial sepsis. Long-term mortality for patients admitted to the ICU ranges from 30% to 50%. Many procedures in ICUs pose a high risk for transmission of SARS coronavirus to health care workers. Contact and airborne infection isolation precautions, in addition to standard precautions, should be applied when caring for patients with SARS. Ensuring staff safety is important to maintain staff morale and delivery of adequate services.