Outcome of patients with systemic rheumatic disease admitted to medical intensive care units.

The outcome of patients admitted to intensive care units is known to be influenced by such factors as age, previous health status, severity of disease, and diagnosis. To estimate the outcome of such patients with systemic rheumatic diseases and to determine if the severity of these diseases unfavourably influences the prognosis at the time of admission to a medical intensive care unit, the clinical courses of all patients with systemic rheumatic disease admitted to two medical intensive care units between January 1978 and December 1988 were studied retrospectively. Sixty nine patients with systemic lupus erythematosus (n = 16), necrotising vasculitis (n = 19), rheumatoid arthritis (n = 19), and other systemic rheumatic diseases (n = 15) were included. The mean (SD) age on admission into the medical intensive care unit was 53 (17) years and the mean simplified acute physiological score was 12 (5.5). The principal diagnoses on admission were infectious complications (29/69 patients) and acute exacerbation of the systemic rheumatic disease (19/69 patients). The death rate in the medical intensive care unit was 33% (23/69 patients) and was similar to that of a non-selected population with comparable simplified acute physiological score. The death rate in hospital was 42% (29/69 patients). Infection was the main cause of death in the medical intensive care unit (19/23 patients) and the infection was mainly acquired in the unit. Only the simplified acute physiological score on admission was a statistically significant prognostic factor: the simplified acute physiological score in patients who died was 15 (5.2) v 9.9 (4.7) for survivors. Long term outcome analysis showed that 83% (33/40 patients) of patients were still alive after admission to the medical intensive care unit with a follow up time between two months and nine years (mean 38 months). The death rate was relatively high and was mainly due to nosocomial infections. It was not different, however, from that of nonselected patients and the long term prognosis was highly favourable. This shows that the complications are often reversible, particularly infectious applications, and justifies admission to the medical intensive care unit of this group of patients.     

The contribution of underlying systemic rheumatic diseases to the mortality in patients admitted for intensive care: a matched cohort study

OBJECTIVE: The aim of this study was to determine the outcome of patients with systemic rheumatic diseases admitted to our medical-intensive care unit (ICU) in comparison to the outcome of patients with non-rheumatic diseases in the same ICU. METHODS: The hospital files of 50 patients with systemic rheumatic diseases who were treated in the medical-ICU of Hacettepe University Hospital, Ankara between 1995 and 2001 were retrospectively evaluated. 50 patients without any underlying systemic rheumatic diseases admitted to the medical-ICU in the same time period and matched for age, gender and acute physiology and chronic health evaluation scores were included in the control group. ICU outcome was compared between the two groups. RESULTS: The acute physiology score of the study group was lower than that of the control group (13.4 +/- 5.7 [SD] vs. 17.3 +/- 7.2, p = 0.04). Moreover, the study group received more immunosuppressive treatment but less invasive procedures (i.e. mechanical ventilation and central venous catheterization). Mortality rates (56% vs. 54%, respectively, p = 0.5), lengths of stay in the ICU and in the hospital, the infection rates were similar between the rheumatic disease group and the control group. CONCLUSION: The presence of a systemic rheumatic disease seems to negatively affect the outcome in patients under intensive care.     

Outcome of patients with scleroderma admitted to intensive care unit. A report of nine cases

OBJECTIVE: Patients with systemic rheumatic disease constitute a small percentage of admissions to the medical intensive care units (ICUs). Systemic sclerosis (SSc) is one of the rheumatic diseases that together with secondary complications may lead to a critical illness requiring hospitalization in the ICU. We present the features, clinical course and outcome of critically ill patients with scleroderma that were admitted to the ICU. METHODS: The medical records of nine patients with diagnosis of scleroderma (8 female, 1 male), admitted to the intensive care unit of Sheba Medical Center during the 11-year interval between 1991 and 2002, were reviewed. RESULTS: The mean age of the patients at the time of admission to the ICU was 48 +/- 13 [SD] years.The mean duration of SSc from diagnosis to the ICU admission was 8 +/- 8 years. Six patients had diffuse SSc, two patients had limited SSc and one patient had juvenile diffuse morphea. The main reasons for admission to the ICU were: infection/ septic syndrome (n = 4), scleroderma renal crisis (SRC) with pulmonary congestion (n = 2), acute renal failure associated with diffuse alveolar hemorrhage namely scleroderma- pulmonary - renal syndrome (SPRS) (n = 1), iatrogenic pericardial tamponade (n = 1), mesenteric ischemia (n = 1). The patients had high severity illness score (mean APACHE II 25 +/- 3). Eight out of nine patients (89%) that were admitted to the ICU died during the hospitalization, six (66.6%) of them died in the ICU. Septic complications as the main cause of death were determined in five patients (62.5%), while four of them had pneumonia and acute respiratory failure along with underlying severe pulmonary fibrosis. Lungs and kidneys were the most common severely affected organs by SSc in our patients. CONCLUSION: The outcome of scleroderma patients admitted to the ICU was extremely poor. Infectious complication was the most common cause of death in our patients. Although infections are treatable, the high mortality rate for this group of patients was dependent on the severity of the underlying visceral organ involvement, particularly severe pulmonary fibrosis. The severity of this involvement is a poor outcome predictor. An early diagnosis and an appropriate treatment of such complications may help to reduce the mortality in scleroderma patients.     

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.     

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 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.     

Outcomes of septic cirrhosis patients admitted to the intensive care unit: A retrospective cohort study

The aim of this study is to examine the outcome of septic patients with cirrhosis admitted to the intensive care unit (ICU) and predictors of mortality.Single center, retrospective cohort study.The study was conducted in Intensive care Department of King Abdulaziz Medical City, Riyadh, Saudi Arabia.Data was extracted from a prospectively collected ICU database managed by a full time data collector. All patients with an admission diagnosis of sepsis according to the sepsis-3 definition were included from 2002 to 2017. Patients were categorized into 2 groups based on the presence or absence of cirrhosis.The primary outcome of the study was in-hospital mortality. Secondary outcomes included ICU mortality, ICU and hospital lengths of stay and mechanical ventilation duration.A total of 7906 patients were admitted to the ICU with sepsis during the study period, of whom 497 (6.29%) patients had cirrhosis. 64.78% of cirrhotic patients died during their hospital stay compared to 31.54% of non-cirrhotic. On multivariate analysis, cirrhosis patients were at greater odds of dying within their hospital stay as compared to non-cirrhosis patients (Odds ratio {OR} 2.53; 95% confidence interval {CI} 2.04 – 3.15) independent of co-morbidities, organ dysfunction or hemodynamic status. Among cirrhosis patients, elevated international normalization ratio (INR) (OR 1.69; 95% CI 1.29-2.23), hemodialysis (OR 3.09; 95% CI 1.76-5.42) and mechanical ventilation (OR 2.61; 95% CI 1.60–4.28) were the independent predictors of mortality.Septic cirrhosis patients admitted to the intensive care unit have greater odds of dying during their hospital stay. Among septic cirrhosis patients, elevated INR and the need for hemodialysis and mechanical ventilation were associated with increased mortality.     

Outcome of adult umbilical cord blood transplant patients admitted to a medical intensive care unit

Umbilical cord blood transplant (UCBT) has emerged as an alternate source of stem cells for transplantation in patients with hematologic malignancies. However, outcomes of adult UCBT patients requiring ICU admission remain unknown. In order to identify predictors of ICU transfer and mortality in UCBT patients, the course and outcome of all adult (> or = 16 years old) patients who underwent UCBT between 1 January 1998 and 31 December 2003 at University Hospitals of Cleveland were analyzed. Forty-four patients underwent UCBT during the study period and 25 (57%) required ICU transfer. Use of a myeloablative preparative regimen was a significant predictor of ICU transfer (P = 0.03). An infusion of higher numbers of nucleated cells was protective from ICU transfer (P = 0.05). For those patients transferred to the ICU, mortality was 72%. The univariate predictors of mortality, at the time of ICU admission were a high APACHE III score (P = 0.0004), use of vasopressors (P = 0.03), and a low platelet count (P = 0.03). We conclude that transfer of UCBT patients to an ICU may be predicted by their preparative regimen, while ICU mortality may be predicted by physiologic parameters upon admission.     

Outcome of patients with systemic lupus erythematosus in intensive care unit

The objective of the study was to identify the causes, outcome and prognosis of severe illness in patients with systemic lupus erythematosus (SLE) requiring intensive care unit (ICU) care in a University Hospital over a five-year period. The design was a cohort study. Forty-eight SLE patients requiring ICU management over a five-year period (January 1997-December 2001) were studied prospectively. Of 48 patients, 14 (29.2%) died, predominantly with multiorgan dysfunction syndrome (MODS). Patients whose APACHE II score was equal to or greater than 20 had higher mortality than those with APACHE score below 20 (60 versus 7.1%; and P < 0.01). All the 18 patients whose health status rated as 'good' survived, while 46.7% of 30 patients whose health rated as 'poor' died (P < 0.01). Patients who had thrombocytopenia associated with sepsis and/or disseminated intravascular coagulopathy (DIC) had the highest mortality (75%, five-year survival). In conclusion, SLE patients admitted to the ICU had a lower mortality rate than some of the previous reports. Patients with SLE with high APACHE score, > or =20, poor health status, thrombocytopenia and multiorgan dysfunction syndrome had poor prognosis in the ICU.     

Prognostic score of short-term survival in HIV-infected patients admitted to medical intensive care units

A retrospective cohort was set up to identify prognostic factors associated with in-hospital survival in HIV-infected patients admitted to medical intensive care units (MICUs), from 1991 to 1994. Survival from MICU admission to hospital discharge (or in-hospital fatal issue) was estimated and a prognostic score at MICU admission was developed. One hundred and thirty patients were recruited of whom 20% were AIDS-free prior to admission. In-hospital mortality rate was 65%. Median survival was 20 days. The following variables were predictive of mortality: Simplified Acute Physioloy Score II (SAPS II): (hazard ratio [HR]=1.5 for 10 points higher, P<10(-3)), time between HIV diagnosis and admission >5 years (HR=2.7, P<10(-4)), hypoalbuminaemia (HR=1.2 per 5 g/l lower, P=0.03). The prognostic score developed was: SAPS II+25 (if time between HIV diagnosis and MICU admission >5 years) albuminaemia (g/l). A new prognostic score including SAPS II, prior HIV history and albuminaemia better reflected the in-hospital mortality than SAPS II alone. Our findings may still be useful to better evaluate the immediate prognosis of current HIV-infected patients admitted to MICU, particularly those naive to antiretroviral therapy or in treatment failure.     

Accuracy of D-dimer:fibrinogen ratio to diagnose pulmonary thromboembolism in patients admitted to intensive care units

Introduction

Pulmonary thromboembolism (PTE) may increase D-dimer and decrease fibrinogen levels. However, in settings such as intensive care units (ICU) and in long-term hospitalised patients, several factors may influence D-dimer and fibrinogen concentrations and make them unreliable indicators for the diagnosis of PTE. The aim of this study was to evaluate the accuracy of D-dimer:fibrinogen ratio (DDFR) for the diagnosis of PTE in ICU patients.

Methods

ICU patients who were suspected of having a first PTE and had no history of using anti-coagulants and contraceptives were included in the study. Levels of D-dimer and fibrinogen were measured for each patient prior to any intervention. Angiography or CT angiography was done in order to establish a definite diagnosis for each patient. Suitable analytical tests were performed to compare means.

Results

Eighty-one patients were included in the study, of whom 41 had PTE and 40 did not. Mean values of D-dimer and fibrinogen were 3.97 ± 3.22 μg/ml and 560.6 ± 197.3 mg/dl, respectively. Significantly higher levels of D-dimer (4.65 ± 3.46 vs 2.25 ± 2.55 μg/ml, p = 0.006) and DDFR (0.913 ± 0.716 vs 483 ± 0.440 × 10^-3, p = 0.003) were seen in PTE patients than in those without PTE. Receiver operating characteristic (ROC) analysis showed a 70.3% sensitivity and 70.1% specificity with a D-dimer value of 2.43 μg/ml (AUC = 0.714, p = 0.002) as the best cut-off point; and a 70.3% sensitivity and 61.6% specificity with a DDFR value of 0.417 × 10^-3 (AUC = 0.710, p = 0.004) as the best cut-off point. In backward stepwise regression analysis, DDRF (OR = 0.72, p = 0.025), gender (OR = 0.76, p = 0.049) and white blood cell count (OR = 1.11, p = 0.373) were modelled (p = 0.029, R² = 0.577).

Conclusion

For diagnosis of PTE, DDFR can be considered to have almost the same importance as D-dimer level. Moreover, it was possible to rule out PTE with only a D-dimer cut-off value < 0.43 mg/dl, without the use of DDFR. However, these values cannot be used as a replacement for angiography or CT angiography     

Short- and long-term prognosis of acute critically ill patients with systemic rheumatic diseases: A retrospective multicentre study

Patients with systemic rheumatic disease (SRD) share the risks of multi-organ flare-up, cardiovascular diseases, and immunosuppression. Such situations can lead to an acute critical illness. The present study describes the clinical features of SRD patients admitted to the intensive care unit (ICU) and their short- and long- term mortality.We performed a multicentre retrospective study in 10 French ICU in Lyon, France. Inclusion criteria were SRD diagnosis and admission for an acute organ failure. The primary endpoint was ICU mortality.A total of 271 patients were included. SRD included systemic lupus erythematosus (23.2% of included patients), vasculitis (10.7%), systemic sclerosis (10.7%), idiopathic inflammatory myopathy (6.3%), and other connective tissue disorders (rheumatoid arthritis, Sjögren and Sharp syndromes; 50.9%). Initial organ failure(s) were shock (43.5% of included patients), acute kidney injury (30.5%), and acute respiratory failure (23.2%). The cause(s) of ICU admission included sepsis (61.6%), cardiovascular events (33.9%), SRD-flare up (32.8%), and decompensations related to comorbidities (28%). The ICU mortality reached 14.3%. The factors associated with ICU mortality were chronic cardiac failure, invasive ventilation and admission in ICU for another reason than sepsis or SRD flare-up. The median follow-up after ICU discharge was 33.6 months. During follow-up, 109 patients died. The factors associated with long-term mortality included age, Charlson comorbidity index, and ICU admission for sepsis or SRD flare-up.The ICU mortality of patients with SRD was low. Sepsis was the first cause of admission. Cardiovascular events and comorbidities negatively impacted ICU mortality. Admission for sepsis or SRD flare-up exerted a negative effect on the long-term outcome.     

Prognosis and outcome of 26 patients with systemic necrotizing vasculitis admitted to the intensive care unit

OBJECTIVES: To investigate presenting features, prognostic factors and outcomes of patients with systemic necrotizing vasculitis (SNV) admitted to the intensive care unit (ICU). METHODS: We retrospectively reviewed the medical records of all 210 SNV patients followed in our university hospital and admitted to the ICU between 1982 and 2001, with respect to clinical features, ICU disease severity scores (APACHE II and SAPS II), the Birmingham vasculitis activity score (BVAS), the five-factors score (FFS) and outcomes. RESULTS: Twenty-six patients (16 men, 10 women) with a mean age of 46.3+/-16.5 yr were included. The reasons for ICU admission were: active SNV, 20 (77%); infection, 3 (12%); others, 3 (12%). SNV was diagnosed in 11 (42%) patients in the ICU. The mean APACHE II and SAPS II scores were significantly higher for patients who died in the ICU (P = 0.01 and P = 0.01 respectively). After a mean follow-up of 31.4+/-29.2 months, the overall mortality rate was 39% (10 patients). Among patients admitted to the ICU with active SNV, BVAS calculated at ICU admission was significantly higher for non-survivors at the end of follow-up (26.9+/-13.0 vs 14.7+/-4.6, P = 0.02). CONCLUSION: The main reason for admitting SNV patients to the ICU was active vasculitis, which was often the first manifestation of SNV and led to its diagnosis. ICU disease severity scores at admission were associated with mortality in the ICU but did not predict long-term outcome, unlike BVAS, which accurately predicted long-term outcome but not ICU prognosis for patients admitted to the ICU with active SNV.     

Prognostic factors of mortality in Iranian patients with systemic lupus erythematosus admitted to intensive care unit

The aim was to determine the course, outcome, and determinants of mortality in patients with systemic lupus erythematosus (SLE) in intensive care unit (ICU). SLE patients admitted to ICU from 2004 to 2015 were recruited retrospectively. Demographic data, disease characteristics, causes of admission, baseline SLE disease activity index-2K (SLEDAI-2K) and Acute Physiologic and Chronic Health Evaluation II (APACHE) score, the outcome, and the causes of death were recorded. Predictors of mortality were compared between alive and dead patients by Cox regression analysis. Ninety-four patients with SLE were enrolled. Mean age at the time of ICU admission was 29.6 years. Average scores of SLEDAI and APACHE II were 11.3 and 19.8, respectively. The most common causes of ICU admission were pneumonia, diffuse alveolar hemorrhage (DAH), and seizure. Forty-seven patients (50%) died in ICU. The principal causes of death were septic shock (25.5%), multi-organ failure (12.5%), DAH (10.6%), and pneumonia (10.6%). After multivariate analysis, high APACHE II, septic shock, and duration of mechanical ventilation were indicators of survival outcome. Mean (95% CI) survival days in ICU in patients with and without respiratory failure were 14.6 (10.4–18.9) and 28.7 (17.9–39.5) days, respectively (P = 0.001). This figure for those with and without septic shock was 13.5 (4.9–11.1) and 22.3 (9.3–24.7) days, respectively (P = 0.016). High APACHE II, septic shock, and duration of mechanical ventilation were the main predictors of death in patients with SLE in ICU. Multicenter studies are needed to draw a fine picture of SLE behavior in ICU.     

Outcome of adult patients with cystic fibrosis admitted to intensive care with respiratory failure: the role of non-invasive ventilation

Recourse to mechanical ventilation may prove necessary in adult patients with cystic fibrosis who have reached the stage of severe respiratory insufficiency. We report the experience of an intensive care service using non-invasive ventilation (NIV) as the first step in the management of acute respiratory failure in these patients. The records of 16 patients with cystic fibrosis presenting with acute respiratory failure and treated with NIV were analysed retrospectively. The characteristics of the group were: mean age 26.9 +/- 9.5 years; mean FEV1 21.5 +/- 10.4% predicted; mean body mass index 16.8 +/- 2.1; mean Pa CO(2) on admission 66 +/- 15 mm Hg. The mean duration of NIV in the ICU was 10 +/- 7 days. Eight patients (50%) died after having been intubated on account of failure of NIV. The eight survivors were discharged home with long-term NIV (mean duration 235 +/- 158 days). Six of them have received a lung transplant. The mode of onset of respiratory failure was an important prognostic factor: a rapid onset (<7 days) was invariably associated with death, on the other hand a gradual deterioration (> 7 days) was noted in the eight patients able to leave the ICU. In conclusion NIV may be regarded as the treatment of choice in patients with cystic fibrosis admitted to ICU with respiratory failure. In the case of persistent hypercapnia after the acute episode long-term NIV may keep them stable while awaiting lung transplantation.