New-onset atrial fibrillation in patients with acute kidney injury on continuous renal replacement therapy

PurposeThe mortality of critically ill patients with acute kidney injury (AKI) who require continuous renal replacement therapy (CRRT) remains high. We assessed the incidence and predictors of new-onset atrial fibrillation (NOAF) in this population and its impact on outcomes.Materials and methodsThis is a retrospective cohort study of adult intensive care units (ICU) patients who had AKI and received CRRT from December 2006 through November 2015 in a tertiary academic medical center. Cox proportional hazard model was used to evaluate the impact of NOAF on overall mortality.ResultsOut of 1398 screened patients, NOAF occurred in 193 (14%) cases. NOAF occurring on CRRT was independently associated with an increased hazard of death at follow-up (HR: 1.26; 95% CI: 1.03–1.56), compared to the group who did not have NOAF. In the multivariable analysis using time-dependent covariates, higher potassium (HR 1.24, 95%CI: 1.01–1.54) and bicarbonate (HR 0.95, 95%CI: 0.92–0.98) levels were associated with increased and decreased risk of NOAF on CRRT, respectively.ConclusionsNOAF in critically ill patients with AKI receiving CRRT is common and carries an unfavorable prognosis. Prospective studies are required to elucidate modifiable risk factors for NOAF occurring on CRRT.     

Endothelium-associated biomarkers mid-regional proadrenomedullin and C-terminal proendothelin-1 have good ability to predict 28-day mortality in critically ill patients with SARS-CoV-2 pneumonia: A prospective cohort study

PurposeWe assessed the ability of mid-regional proadrenomedullin (MR-proADM) and C-terminal proendothelin-1 (CT-proET-1) to predict 28-day mortality in critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia.MethodsBiomarkers were collected during the first seven days in this prospective observational cohort study. We investigated the relationship between biomarkers and mortality in a multivariable Cox regression model adjusted for age and SOFA score.ResultsIn 105 critically ill patients with confirmed SARS-CoV-2 pneumonia 28-day mortality was 28.6%. MR-proADM and CT-proET-1 were significantly higher in 28-day non-survivors at baseline and over time. ROC curves revealed high accuracy to identify non-survivors for baseline MR-proADM and CT-proET-1, AUC 0.84, (95% CI 0.76–0.92), p < 0.001 and 0.79, (95% CI 0.69–0.89), p < 0.001, respectively. The AUC for prediction of 28-day mortality for MR-proADM and CT-proET-1 remained high over time. MR-proADM ≥1.57 nmol/L and CT-proET-1 ≥ 111 pmol/L at baseline were significant predictors for 28-day mortality (HR 6.80, 95% CI 3.12–14.84, p < 0.001 and HR 3.72, 95% CI 1.71–8.08, p 0.01).ConclusionBaseline and serial MR-proADM and CT-proET-1 had good ability to predict 28-day mortality in critically ill patients with SARS-CoV-2 pneumonia.Trial registrationNEDERLANDS TRIAL REGISTER, NL8460.     

Safety of off-label erythropoiesis stimulating agents in critically ill patients: a meta-analysis

Purpose

Erythropoiesis stimulating agents (ESAs) are used to treat anemia in critically ill patients. This indication is off-label, because it is not licensed by regulatory authorities. Recently ESAs were suspected to harm critically ill patients. Our objective was to assess the safety of ESAs in off-label indications in critically ill patients.

Methods

Eleven databases were searched up to April 2012. We considered randomized controlled trials (RCTs) and controlled observational studies in any language that compared off-label ESAs treatment with other effective interventions, placebo or no treatment in critically ill patients. Two authors independently screened and evaluated retrieved records, extracted data and assessed risk of bias and quality of reporting.

Results

We used frequentist and Bayesian models to combine studies, and performed sensitivity and subgroup analyses. From 12,888 citations, we included 48 studies (34 RCTs; 14 observational), involving 944,856 participants. Harm reporting was of medium to low quality. There was no statistically significant increased risk of adverse events in general, serious adverse events, the most frequently reported adverse events, and death in critically ill patients treated with ESAs. These results were robust against risk of bias and analysis methods. There is evidence that ESAs increase the risk of clinically relevant thrombotic vascular events, and there is some less certain evidence that ESAs might increase the risk for venous thromboembolism.

Conclusions

In critically ill patients, administration of ESAs is associated with a significant increase in clinically relevant thrombotic vascular events but not with other frequently reported adverse events and death.     

Effect of thiamine supplementation in critically ill patients: A systematic review and meta-analysis

IntroductionSeveral studies have previously shown the benefit of thiamine supplementation in critically ill patients. In order to fully appraise the available data, we performed a meta-analysis of 18 published studies.MethodsA thorough systematic search was conducted. The studies enrolling critically ill patients receiving thiamine supplementation was compared with the standard of care (SOC) group. Data was analyzed using RevMan 5.4. Clinical outcomes were pooled using Odds Ratio (OR) and mean differences.ResultEighteen studies (8 RCTs and 10 cohort studies) met the criteria for quantitative synthesis. In the analysis of RCTs, thiamine supplementation showed 42% lower odds of developing ICU delirium (OR 0.58, 95% CI, 0.34–0.98). A reduction in mortaliy was observed on performing fixed effect model analysis however, a level of statistical significance could not be reached on performing random effect model analysis (OR, 0.78; 95% CI, 0.59 to 1.04). Further sub-group analysis of 13 studies in patients with sepsis, there was no difference in mortality between the two groups (OR, 0.83; 95% CI, 0.63 to 1.09).ConclusionThiamine supplementation in critically ill patients showed a reduction in the incidence of ICU delirium among RCTs. However, there was no significant benefit in terms of overall mortality, and mortality in patients with sepsis. Further, large scale randomized prospective studies are warranted to investigate the role of thiamine supplementation in critically ill patients.     

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.     

Impact of neutropenia duration on short-term mortality in neutropenic critically ill cancer patients

OBJECTIVE: To identify predictors of 30-day mortality and to assess the impact of neutropenia recovery (NR) on 30-day mortality in critically ill cancer patients (CICPs). DESIGN AND SETTING: Retrospective review of the medical records of the 102 neutropenic CICPs admitted to a medical intensive care unit (ICU) over a 10-year period. INTERVENTION: None. MEASUREMENTS AND RESULTS: Malignancies consisted of acute leukemia (n=42), lymphoma (n=23), myeloma (n=28), and solid tumors (n=9). Reasons for ICU admission were acute respiratory failure (n=81), shock (n=58), acute renal failure (n=33), and coma (n=13). Seventy patients needed conventional mechanical ventilation (MV) and 21 noninvasive MV, 67 vasopressor agents, and 28 dialysis. Sixty-two patients experienced NR during their ICU stay. In a multivariate logistic regression model, 30-day mortality was higher in patients with acute respiratory or renal failure and lower in patients with NR (OR, 0.09 [0.01-0.86]). This model assumed that patients who experienced NR in the ICU were merely these who did not die early in the ICU. To take into account the effect of time to occurrence of NR on time to death we secondarily used a Cox model including neutropenia duration and NR as time-dependent variables. In this second model, the only significant predictors of 30-day mortality were age, respiratory failure, renal failure, and coma. CONCLUSION: Organ failure but not disease progression or neutropenia duration affect 30-day mortality in neutropenic CICPs. ICU-acquired events might be modeled as time-dependent variables in a Cox model, rather than standard covariates in logistic regression models.     

Comparison of different methodological approaches to identify risk factors of nosocomial infection in intensive care units

OBJECTIVE: Comparison of statistical methods and measurement scales to identify nosocomial infection risk factors in intensive care units (ICU). DESIGN: Prospective study in 558 patients admitted to the ICU of a referral hospital between February and November 1994. METHODS: Analysis using three logistic regression models, three standard Cox regression models, and two Cox regression models with time-dependent extrinsic factors. Different scales were used to measure exposures to risk factors (dichotomous, ordinal, quantitative, and time-dependent variables). RESULTS: The most appropriate models were those that measured exposure using dichotomous variables. Models using ordinal or quantitative variables estimated biased coefficients and/or failed to comply with the statistical assumptions underlying the analyses. The Cox regression model with quantitative time-dependent variables met all the statistical assumptions, obtained a precise assessment of risk by exposure time, and estimated unbiased coefficients. CONCLUSIONS: The Cox regression analysis with quantitative time-dependent variables is the most valid alternative for assessing the risk of nosocomial infection per day of exposure to an extrinsic risk factor in the ICU.     

Prognostic importance of neutrophil-lymphocyte ratio in critically ill patients: short- and long-term outcomes

Study objectiveThe number of critically ill patients admitted to the emergency department increases daily. To decrease mortality, interventions and treatments should be conducted in a timely manner. It has been found that the neutrophil-lymphocyte ratio (NLR) is related to mortality in some disease groups, such as acute coronary syndrome and pulmonary emboli. The effect of the NLR on mortality is unknown in critically ill patients who are admitted to the emergency department. Our aim in this study is to evaluate the effect of the NLR on mortality in critically ill patients.MethodsThis study was planned as a prospective, observational cohort study. Patients who were admitted to the emergency department because they were critically ill and required the intensive care unit were included in the study. Demographic characteristics, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sepsis-related Organ Failure Assessment, Glasgow Coma Score, and NLR values were recorded upon emergency department admission. The patients were followed up for sepsis, ventilator-associated pneumonia, multiorgan failure, in-hospital mortality, and 6-month mortality.ResultsThe median (interquartile range) age of the 373 patients was 74 (190) years, and 54.4% were men. Neutrophil-lymphocyte ratio values were divided into quartiles, as follows: less than 3.48, 3.48 to 6.73, 6.74-13.6, and more than 13.6. There was no difference among these 4 groups regarding demographic characteristics, APACHE II score, Sepsis-related Organ Failure Assessment score, Glasgow Coma Score, and length of hospital stay (P > .05). In the multivariable Cox regression model, in-hospital mortality and 6-month mortality NLR were hazard ratio (HR), 1.63 (1.110-2.415; P = .01) and HR, 1.58 (1.136-2.213; P = .007), respectively, and APACHE II scores were detected as independent indicators.ConclusionThe NLR is a simple, cheap, rapidly available, and independent indicator of short- and long-term mortalities. We suggest that the NLR can provide direction to emergency department physicians for interventions, particularly within a few hours after admission, in the critically ill patient group.     

Effect of a Clinical Nursing Practice Guideline of Enteral Nutrition Care on the Duration of Mechanical Ventilator for Critically Ill Patients

PurposeEarly enteral nutrition (EN) can improve clinical outcomes in critically ill patients. This study aimed to evaluate the effects of this clinical nursing practice guideline (CNPG) of EN care on the duration of mechanical ventilator in critically ill patients to investigate whether it was able to improve clinical outcomes.MethodsThis study compares a pretest-posttest design for the two groups, which was done before and after to determine the effects of a CNPG of EN care on the duration of a mechanical ventilator in critically ill patients. This study was performed on 44 critically ill patients admitted to the intensive care unit (ICU). The patients were divided into two groups according to EN. For the intervention group, CNPG started within the first 48 hours of admission to the ICU, and for the control group, they received standard nursing care.ResultsAfter the implementation, it showed significant associations between the duration of mechanical ventilator in ICU. The intervention group who received the CNPG had significantly shorter starting time of EN and a reduced duration of mechanical ventilator than those in the control group (p < .001).ConclusionA CNPG for EN care reduced the duration of mechanical ventilator. This could possibly improve the delivery of target calories when compared with current standard practice and improve the outcome of critically ill patients.     

The association between the neutrophil-to-lymphocyte ratio and mortality in critical illness: an observational cohort study

IntroductionThe neutrophil-to-lymphocyte ratio (NLR) is a biological marker that has been shown to be associated with outcomes in patients with a number of different malignancies. The objective of this study was to assess the relationship between NLR and mortality in a population of adult critically ill patients.MethodsWe performed an observational cohort study of unselected intensive care unit (ICU) patients based on records in a large clinical database. We computed individual patient NLR and categorized patients by quartile of this ratio. The association of NLR quartiles and 28-day mortality was assessed using multivariable logistic regression. Secondary outcomes included mortality in the ICU, in-hospital mortality and 1-year mortality. An a priori subgroup analysis of patients with versus without sepsis was performed to assess any differences in the relationship between the NLR and outcomes in these cohorts.ResultsA total of 5,056 patients were included. Their 28-day mortality rate was 19%. The median age of the cohort was 65 years, and 47% were female. The median NLR for the entire cohort was 8.9 (interquartile range, 4.99 to 16.21). Following multivariable adjustments, there was a stepwise increase in mortality with increasing quartiles of NLR (first quartile: reference category; second quartile odds ratio (OR) = 1.32; 95% confidence interval (CI), 1.03 to 1.71; third quartile OR = 1.43; 95% CI, 1.12 to 1.83; 4th quartile OR = 1.71; 95% CI, 1.35 to 2.16). A similar stepwise relationship was identified in the subgroup of patients who presented without sepsis. The NLR was not associated with 28-day mortality in patients with sepsis. Increasing quartile of NLR was statistically significantly associated with secondary outcome.ConclusionThe NLR is associated with outcomes in unselected critically ill patients. In patients with sepsis, there was no statistically significant relationship between NLR and mortality. Further investigation is required to increase understanding of the pathophysiology of this relationship and to validate these findings with data collected prospectively.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0731-6) contains supplementary material, which is available to authorized users.     

An approach to develop clinical prediction rule for candidemia in critically ill patients: A retrospective observational study

PurposeEarly detection of candidemia in critically ill patients is important for preemptive antifungal treatment. Our study aimed to identify the independent risk factors for the development of a new candidemia prediction score.MethodsThis single-centre retrospective observational study evaluated 2479 intensive care unit (ICU) cases from January 2016 to December 2018. A total of 76 identified candidemia cases and 76 matched control cases were analyzed. The patients' demographic characteristics and illness severity were analyzed, and possible risk factors for candidemia were investigated.ResultsMultivariate logistic regression analysis identified renal replacement therapy (RRT) (odds ratio [OR]: 52.83; 95% confidence interval [CI]: 7.82–356.92; P < 0.0001), multifocal Candida colonization (OR: 23.55; 95% CI: 4.23–131.05; P < 0.0001), parenteral nutrition (PN) (OR: 63.67; 95% CI: 4.56–889.77; P = 0.002), and acute kidney injury (AKI) (OR: 7.67; 95% CI: 1.24–47.30; P = 0.028) as independent risk factors. A new prediction score with a cut-off value of 5.0 (80.3% sensitivity and 77.3% specificity) was formulated from the logit model equation.ConclusionsRenal replacement therapy, AKI, PN, and multifocal Candida colonization were the independent risk factors for the new candidemia prediction score with high discriminatory performance and predictive accuracy.     

Serum cholesterol as a predictor of mortality among the elderly patients with pneumonia in the emergency department

BackgroundReduced cholesterol levels are associated with poor outcomes in critically ill patients. However, the effect of reduced cholesterol levels on the prognosis of patients with community-acquired pneumonia (CAP) is unclear. This study aimed to investigate the association between serum total cholesterol levels and the clinical outcomes of elderly patients with CAP.MethodsThis was a retrospective observational study that included elderly (≥65 years) CAP patients hospitalized through emergency department between January 2016 and December 2019. We collected their baseline characteristics and laboratory data, including total cholesterol levels at the time of admission. Univariate and multivariate analyses were performed to determine the association between total cholesterol levels and 14-day in-hospital mortality.ResultsA total of 380 patients were included. The overall 14-day in-hospital mortality rate was 12.37%. Survivors had higher total cholesterol levels than non-survivors (median, 125 mg/dL; interquartile range [IQR], 102–151 mg/dL versus median, 100 mg/dL; IQR, 83–126 mg/dL; p < 0.001). Multivariate analysis using a logistic regression model showed that a total cholesterol level of <97 mg/dL was independently associated with 14-day in-hospital mortality in patients with CAP (odds ratio, 2.93; 95% confidence interval, 1.13–7.599; p = 0.027).ConclusionsA decreased level of total cholesterol was associated with increased short-term mortality in elderly patients with CAP. Initial total cholesterol levels may be a useful biomarker to predict the outcome of patients with CAP.     

Nurse led protocols for control of glycaemia in critically ill patients: A systematic review

BackgroundBlood glucose control in critically ill patients is challenging and can affect clinical outcomes. Several manual as well as automated approaches have been proposed over the time, however nursing staff still covers the key-role for optimization of glycemia throughout adjustment of insulin infusion and administration.AimSystematic review to compare the efficacy/the effects of nurse led insulin infusion protocols versus standard approaches in patients admitted in the intensive care unit.MethodsAll relevant studies evaluating nurse directed protocols for insulin administration in critically ill adults. Data was independently extracted and collected through a dedicated electronic form. The following outcomes have been recorded: the number (or percentage) of glycaemia measurements within the target range; the number of hypo- and hyper-glycaemic events, separately; the mean glycaemia; the lowest and highest glycemia values recorded; the time to reach the glycaemia target; the ICU length of stay and the ICU and the long-term (>30 days) mortality. Statistical analysis was conducted on the summary statistics of the selected articles (eg, means, medians, proportions). Unpaired nonparametric continuous data were compared through the Mann-Whitney U-test.ResultsGlycaemic control as well as ICU length of stay and mortality are similar in both patients' groups. Specifically, the group of patients treated with standard modalities include those treated with doctors led protocols, paper charts or software-based approaches.ConclusionOverall, nurse led insulin protocols can effectively control blood glucose level among critically ill patients.     

Isolated diastolic dysfunction is associated with increased mortality in critically ill patients

PurposeLeft ventricular (LV) diastolic dysfunction is important in critically ill patients, but prevalence and impact on mortality is not well studied. We classified intensive care patients with normal left ventricular function according to current diastolic guidelines and explored associations with mortality.Material and methodsEchocardiography was performed within 24 h of intensive care admission. Patients with reduced LV ejection fraction, regional wall motion abnormality, or a history of cardiac disease were excluded. Patients were classified according to the 2016 EACVI guidelines, Recommendations for the Evaluation of LV Diastolic Function by Echocardiography.ResultsOut of 218 patients, 162 (74%) had normal diastolic function, 21 (10%) had diastolic dysfunction, and 35 (17%) had indeterminate diastolic function.Diastolic dysfunction were more common in female patients, older patients and associated with sepsis, respiratory and cardiovascular comorbidity as well as higher SAPS Score. In a risk-adjusted logistic regression model, patients with indeterminate diastolic dysfunction (OR 4.3 [1.6–11.4], p = 0.004) or diastolic dysfunction (OR 5.1 [1.6–16.5], p = 0.006) had an increased risk of death at 90 days compared to patients with normal diastolic function.ConclusionIsolated diastolic dysfunction, assessed by a multi-parameter approach, is common in critically ill patients and is associated with mortality.Trial registrationSecondary analysis of data from a single-center prospective observational study focused on systolic dysfunction in intensive care unit patients (Clinical Trials ID: NCT03787810     

Development of a performance standard for physiotherapists delivering exercise and mobilisation to the critically ill: A modified Delphi consensus study

BackgroundThe provision of early mobilisation to critically ill patients has the potential to improve long term outcomes, but, is complex to deliver. There is minimal literature detailing the training and expertise required to deliver these interventions safely and effectively.ObjectiveThe objective of this study was to determine the key elements of a performance standard for assessment of physiotherapists delivering exercise and mobilisation interventions to the critically ill.MethodThis is a modified eDelphi expert consensus study. Fifty-one physiotherapists from Australia and New Zealand with relevant clinical, educational, or research experience were included on the expert panel. Background information and the initial pool of items were developed from review of relevant literature. Five survey rounds were administered across two study phases to determine the elements, performance criteria, and assessment scale of the performance standard. Items were modified, amalgamated, and added based upon panel comments.ResultsConsensus was achieved for 69 mandatory, and two supplementary performance criteria which were arranged under 15 elements encompassing knowledge, assessment, analysis, intervention, and professional behaviours. A 3-point rating scale was selected to assess item achievement and global performance.ConclusionBinational expert consensus was reached to define the assessment criteria for physiotherapists delivering exercise and mobilisation interventions to the critically ill. This standard can be utilised in clinical, educational, and research practice environments to guide training, assessment, and skill recognition in critical care physiotherapy.     

Methadone analgesia in the critically ill

PurposeMethadone is increasingly used as an analgesic or a bridge to weaning other analgesics and sedatives in critically ill patients. This review discusses the pharmacology of methadone, summarizes available evidence for its use in the intensive care unit setting, and makes suggestions for appropriate use and monitoring.Materials/methodsArticles evaluating the efficacy, safety, and pharmacology of methadone were identified from a PubMed search through June 2015. References from selected articles were reviewed for additional material. Experimental and observational English-language studies that focused on the efficacy, safety, and pharmacology of methadone in critically-ill adults and children were selected.ResultsMethadone is a synthetic opioid analgesic with potential advantages over other commonly used opioids. Limited evidence from critically ill pediatric, adult, and burn populations suggests that methadone protocols may expedite weaning opiate infusions, decrease the length of mechanical ventilation, and reduce the incidence of negative outcomes such as opiate withdrawal, delirium, and over-sedation.ConclusionsData from current literature supports a role for methadone analgesia in weaning opiates and potentially reducing the duration of mechanical ventilation in critically ill patients. More studies are needed to confirm these benefits and determine criteria for patient selection.     

Pharmacokinetics of levetiracetam in neurosurgical ICU patients

Background/objectivesThe pharmacokinetics (PK) of drugs is dramatically altered in critical illness. Augmented renal clearance (ARC), a phenomenon characterized by creatinine clearance (CrCl) greater than 130 ml/min/1.73m², is commonly described in critically ill patients. Levetiracetam, an antiepileptic drug commonly prescribed for seizure prophylaxis in the neurosurgical ICU, undergoes predominant elimination via the kidneys. Hence, we hypothesize that current dosing practice of intravenous (IV) levetiracetam 500 mg twice daily is inadequate for critically ill patients due to enhanced drug elimination. The objectives of our study were to describe the population PK of levetiractam using a nonparametric approach to design an optimal dosing regimen for critically ill neurosurgical patients.MethodsThis was a prospective, observational, population PK study. Serial blood samples were obtained from neurosurgical ICU patients who received at least one dose of IV levetiracetam. We used uHPLC to analyze these samples and Pmetrics™ software to perform PK analysis.ResultsTwenty subjects were included, with a median age of 54 years and CrCl of 104 ml/min. A two-compartmental model with linear elimination adequately described the profile of levetiracetam. Mean clearance (CL) was 3.55 L/h and volume of distribution (V) was 18.8 L. No covariates were included in the final model. Monte Carlo simulations showed a low probability of target attainment (PTA, trough at steady state of ≥6 mg/L) with a standard dose of 500 mg twice daily. A dose of at least 1000 mg twice daily was required to achieve 80% PTA. Two subjects, both with subtherapeutic trough levels, developed early onset seizures.ConclusionOur study examined the population PK of levetiracetam in a critically ill neurosurgical population. We found that this population displayed higher clearance and required higher doses to achieve target levels.     

Treating Critical Illness Caused by the 2009 H1N1 Influenza A Virus

Background

The 2009 H1N1 influenza A pandemic has set the world spinning, unexpectedly producing significant morbidity and mortality in young, otherwise healthy patients.

Discussion

As the virus spreads across the Northern Hemisphere, emergency physicians are confronted with the challenging task of caring for the many that become critically ill from this pathogen. With the exception of a few observational studies and case reports, there is little information to guide the emergency physician in resuscitating and delivering critical care to a rapidly deteriorating patient. Many moribund patients with 2009 H1N1 influenza A infection require non-conventional critical care therapies.

Conclusion

In this article, we describe the case of a critically ill patient with confirmed 2009 H1N1 influenza A infection. After a brief review of the unique characteristics of this virus, we discuss the management of critically ill patients burdened by infection with 2009 H1N1 influenza A.     

Independent risk factors for the development of incontinence-associated dermatitis (category 2) in critically ill patients with fecal incontinence: A cross-sectional observational study in 48 ICU units

BackgroundCritically ill patients suffering from fecal incontinence have a major risk of developing incontinence-associated dermatitis (IAD). The presence of moisture and digestive enzymes (lipase, protease) negatively influences skin barrier function. Additional risk factors will make some patients even more vulnerable than others. In order to provide (cost) effective prevention, this specific patient population should be identified timely.ObjectivesTo identify independent risk factors for the development of IAD category 2 (skin loss) in critically ill patients with fecal incontinence.DesignA cross-sectional observational study.Setting and participantsThe study was performed in 48 ICU wards from 27 Belgian hospitals. Patients of 18 years or older, with fecal incontinence at the moment of data collection, were eligible to participate. Patients with persistent skin redness due to incontinence (IAD category 1) were excluded.MethodsPotential risk factors were carefully determined based on literature and expert consultations. Data were collected over a period of eight months by trained researchers using patient records and observation of skin care practices. At the time a patient was included in the study, all relevant data from the past six days, or since admission at the ICU, were recorded. Simultaneously, direct skin observations were performed and high definition photographs were ratified by an expert IAD researcher. A multiple binary logistic regression model was composed to identify independent risk factors. Variables with P < .25 in single binary logistic regression analyses were added to the multiple model using a forward procedure. A cut-off value of P < .1 was established to retain variables in the final model. Nagelkerke’s R² and Hosmer-Lemeshow statistic were calculated as measures of model fit.ResultsThe sample comprised of 206 patients, of which 95 presented with IAD category 2, and 111 were free of IAD. Seven independent risk factors were identified: liquid stool [odds ratio (OR) 4.69; 95% confidence interval (CI) 2.28–9.62], diabetes (OR 2.89; 95% CI 1.34–6.27), age (OR 1.05; 95% CI 1.02–1.08), smoking (OR 2.67; 95% CI 1.21–5.91), non-use of diapers (OR 2.97; 95% CI 1.39–6.33), fever (OR 2.60; 95% CI 1.23–5.53), and low oxygen saturation (OR 2.15; 95% CI 1.03–4.48). Nagelkerke’s R² was 0.377. The Hosmer-Lemeshow statistic indicated no significant difference between the observed and expected values (p = .301).ConclusionsLiquid stool, diabetes, age, smoking, non-use of diapers, fever, and low oxygen saturation were independently associated with IAD category 2 in critically ill patients with fecal incontinence.     

Outcome prediction model for very elderly critically ill patients

CONTEXT: Very elderly critically ill patients have three possible hospital outcomes: discharge to home, discharge to a skilled nursing or rehabilitation facility, or death. The factors associated with these outcomes are unknown. OBJECTIVE: To develop a three-outcome prediction model for very elderly critically ill patients. DESIGN: Retrospective chart abstraction with ordered logistic regression analysis. SETTING: Academic medical center. PATIENTS: Four hundred and fifty-five patients 85 yrs or older admitted to intensive care units (ICU) during 1996 and 1997. MEASUREMENTS AND MAIN RESULTS: A fitted ordinal logistic regression predictive model was developed using data from 243 patients hospitalized in 1996, and validated on data from 212 patients hospitalized in 1997. Model variables include age, gender, baseline support level, type of ICU, heart rate at ICU admission, use of mechanical ventilation, vasopressors or a pulmonary artery catheter during the ICU stay, and the development of respiratory, neurologic or hematologic failure or sepsis while in the ICU. When tested on the 1997 data, the model was well calibrated and had a high discriminant index. CONCLUSIONS: This mathematical model can be used to predict the risks of these three hospital outcomes for this population of patients. These predictions can provide a context when discussing goals and expectations with patients, families, and other healthcare providers and to aid in hospital discharge planning.