Early intervention on the outcomes in critically ill cancer patients admitted to intensive care units

Purpose

To determine whether earlier intervention was associated with decreased mortality in critically ill cancer patients admitted to an intensive care unit (ICU).

Methods

A retrospective observational study was performed of 199 critically ill cancer patients admitted to the ICU from the general ward between January 2010 and December 2010. A logistic regression model was used to adjust for potential confounding factors in the association between time to intervention and in-hospital mortality.

Results

In-hospital mortality was 52?%, with a median Simplified Acute Physiology Score 3 (SAPS 3) of 80 [interquartile range (IQR) 67–93], and a median Sequential Organ Failure Assessment (SOFA) score of 8 (IQR 5–11). Median time from physiological derangement to intervention (time to intervention) prior to ICU admission was 1.5 (IQR 0.6–4.3)?h. Median time to intervention was significantly shorter in survivors than in non-survivors (0.9 vs. 3.0?h; p?p?2/FiO₂ ratio. Even after adjusting for potential confounding factors, time to intervention was still significantly associated with hospital mortality (adjusted odds ratio 1.445, 95?% confidence interval 1.217–1.717).

Conclusions

Early intervention before ICU admission was independently associated with decreased in-hospital mortality in critically ill cancer patients admitted to the ICU.     

Invasive pulmonary aspergillosis is a frequent complication of critically ill H1N1 patients: a retrospective study

Purpose

Despite their controversial role, corticosteroids (CS) are frequently administered to patients with H1N1 virus infection with severe respiratory failure secondary to viral pneumonia. We hypothesized that invasive pulmonary aspergillosis (IPA) is a frequent complication in critically ill patients with H1N1 virus infection and that CS may contribute to this complication.

Methods

We retrospectively selected all adult patients with confirmed H1N1 virus infection admitted to the intensive care unit (ICU) of two tertiary care hospitals from September 2009 to March 2011. Differences in baseline factors, risk factors, and outcome parameters were studied between patients with and without IPA.

Results

Of 40 critically ill patients with confirmed H1N1, 9 (23?%) developed IPA 3?days after ICU admission. Five patients had proven and four had probable IPA. Significantly more IPA patients received CS within 7?days before ICU admission (78 versus 23?%, p?=?0.002). IPA patients also received significantly higher doses of CS before ICU admission [hydrocortisone equivalent 800 (360–2,635) versus 0 (0–0)?mg, p?=?0.005]. On multivariate analysis, use of CS before ICU admission was independently associated with IPA [odds ratio (OR) 14.4 (2.0–101.6), p?=?0.007].

Conclusions

IPA was diagnosed in 23?% of critically ill patients with H1N1 virus infection after a median of 3?days after ICU admission. Our data suggest that use of CS 7?days before ICU admission is an independent risk factor for fungal superinfection. These findings may have consequences for clinical practice as they point out the need for increased awareness of IPA, especially in those critically ill H1N1 patients already receiving CS.     

Levosimendan infusion in newborns after corrective surgery for congenital heart disease: randomized controlled trial

Purpose

To evaluate the safety and efficacy of levosimendan in neonates with congenital heart disease undergoing cardiac surgery with cardiopulmonary bypass (CPB).

Methods

Neonates undergoing risk-adjusted classification for congenital heart surgery (RACHS) 3 and 4 procedures were randomized to receive either a 72?h continuous infusion of 0.1?μg/kg/min levosimendan or standard post-CPB inotrope infusion.

Results

Sixty-three patients (32 cases and 31 controls) were recruited. There were no differences between groups regarding demographic and baseline clinical data. No side effects were observed. There were no significant differences in mortality (1 vs. 3 patients, p?=?0.35), length of mechanical ventilation (5.9?±?5 vs. 6.9?±?8?days, p?=?0.54), and pediatric cardiac intensive care unit (PCICU) stay (11?±?8 vs. 14?±?14?days, p?=?0.26). Low cardiac output syndrome occurred in 37?% of levosimendan patients and in 61?% of controls (p?=?0.059, OR 0.38, 95?% CI 0.14–1.0). Postoperative heart rate, with a significant difference at 6 (p?=?0.008), 12 (p?=?0.037), and 24?h (p?=?0.046), and lactate levels, with a significant difference at PCICU admission (p?=?0.015) and after 6?h (p?=?0.048), were lower in the levosimendan group. Inotropic score was significantly lower in the levosimendan group at PCICU admission, after 6?h and after 12?h, (p?Conclusions Levosimendan infused in neonates undergoing cardiac surgery was well tolerated with a potential benefit of levosimendan on postoperative hemodynamic and metabolic parameters of RACHS 3–4 neonates.     

Effects of a 12-week home-based exercise program on the level of physical activity, insulin, and cytokines in colorectal cancer survivors: a pilot study

Purpose

The purposes of this study are to examine (1) the feasibility and efficacy of two different home-based exercise protocols on the level of physical activity (PA), and (2) the effect of increased PA via home-based exercise program on biomarkers of colorectal cancer.

Methods

Seventeen patients (age 55.18 ± 13.3 years) with stage II–III colorectal cancer completed the 12-week home-based exercise program. Subjects were randomized into either casually intervened home-based exercise group (CIHE) or intensely intervened home-based exercise group (IIHE). The primary outcome was the level of PA. Furthermore, insulin, homeostasis model assessment of insulin resistance, insulin-like growth factor axis, and adipocytokines were measured.

Results

Both CIHE and IIHE program significantly increased the level of PA at 12 weeks compared to its level at baseline (CIHE, 10.00?±?8.49 vs. 46.07?±?45.59; IIHE, 12.08?±?11.04 vs. 35.42?±?27.42 MET hours per week). Since there was no difference in PA change between groups (p?=?0.511), the data was combined in analyzing the effects of increased PA on biomarkers. Increase in PA significantly reduced insulin (6.66?±?4.58 vs. 4.86?±?3.48 μU/ml, p?=?0.006), HOMA-IR (1.66?±?1.23 vs. 1.25?±?1.04, p?=?0.017), and tumor necrosis alpha-α (TNF-α 4.85?±?7.88 vs. 2.95?±?5.38 pg/ml, p?=?0.004), and significantly increased IGF-1 (135.39?±?60.15 vs. 159.53 ng/ml, p?=?0.007), IGF binding protein (IGFBP)-3 (2.67?±?1.48 vs. 3.48?±?1.00 ng/ml, p?=?0.013), and adiponectin (6.73?±?3.07 vs. 7.54?±?3.96 μg/ml, p?=?0.015).

Conclusion

CIHE program was as effective as IIHE program in increasing the level of PA, and the increase in PA resulted in significant change in HOMA-IR, IGF-1 axis, TNF-α, and adiponectin levels in stage II–III colorectal cancer survivors.     

Vitamin?D status in critically ill children

Background

Hypovitaminosis?D is an independent risk factor for cardiovascular disease, muscle weakness, impaired metabolism, immune dysfunction, and compromised lung function. Hypovitaminosis?D is common in critically ill adults and has been associated with adverse outcomes. The prevalence of hypovitaminosis?D and its significance in critically ill children are unclear.

Methods

We performed a prospective study to determine the prevalence of hypovitaminosis?D in 316 critically ill children, and examined its association with physiological and biochemical variables, length of pediatric intensive care unit (PICU) stay, and hospital mortality.

Results

The prevalence of hypovitaminosis?D [25(OH)D₃ <50?nmol/L] was 34.5?%. Hypovitaminosis?D was more common in postoperative cardiac patients than in general medical ICU patients (40.5 versus 22.6?%, p?=?0.002), and the cardiac patients had a higher inotrope score [2.5 (1.9–3.3) versus 1.4 (1.1–1.9), p?=?0.006]. Additionally, ionized calcium within the first 24?h was lower in patients with 25(OH)D₃ <50?nmol/L [1.07 (0.99–1.14)?mmol/L] compared with patients with normal vitamin?D₃ [1.17 (1.14–1.19)?mmol/L, p?=?0.02]. Hypovitaminosis?D was not associated with longer PICU stay or increased hospital mortality.

Conclusions

Hypovitaminosis?D is common in critically ill children, and is associated with higher inotropes in the postoperative cardiac population, but not with PICU length of stay or hospital survival.     

The relationship between blood lactate concentration, the Paediatric Index of Mortality 2 (PIM2) and mortality in paediatric intensive care

Introduction

Blood lactate concentration predicts mortality in neonates, infants, children and adults, with evidence that it has better predictive power than other markers of acid–base status such as absolute base excess or pH.

Objective

To investigate whether blood lactate concentration on admission predicts mortality in paediatric intensive care and if its addition can improve the performance of the Paediatric Index of Mortality?2 (PIM2) mortality prediction score.

Design and setting

Retrospective cohort study in one 20-bed UK paediatric intensive care unit (PICU) using data from the PICU clinical and blood gas analyser databases between 2006 and 2010. Only cases with a blood lactate concentration measured at the same time as the PIM2 variables were included. Logistic regression was used to assess if blood lactate concentration predicted mortality independently of PIM2, adjusting for potential confounders, and if it could replace absolute base excess in the PIM2 model.

Results

There were 155 deaths amongst 2,380 admissions (6.5?%). Admission lactate in non-survivors was higher than in survivors (mean [standard deviation, SD]) 6.6 [5.6] versus 3.0 [2.5]?mmol/l, had a positive association with mortality [adjusted odds ratio (OR) for death per unit (mmol/l)] increase 1.11 [95?% confidence interval (CI) 1.06–1.16; p?<?0.001] and significantly improved the model fit of PIM2 when it replaced absolute base excess (p?<?0.001).

Conclusions

PICU admission blood lactate concentration predicts mortality independently of PIM2. Given the limitations of this study, a prospective multi-centre evaluation is required to establish whether it should be added to the PIM2 model with or without replacement of base excess.     

Small increases in serum creatinine are associated with prolonged ICU stay and increased hospital mortality in critically ill patients with cancer

Purpose

Declining kidney function has been associated with adverse hospital outcome in cancer patients. ICU literature suggests that small changes in serum creatinine are associated with poor outcome. We hypothesized that reductions in renal function previously considered trivial would predict a poor outcome in critically ill patients with malignant disease. We evaluated the effects on hospital mortality and ICU length of stay of small changes in creatinine following admission to the intensive care unit.

Methods

We conducted a retrospective cohort study utilizing clinical, laboratory and pharmacy data collected from 3,795 patients admitted to the University of Texas M.D. Anderson Cancer Center's Intensive Care Unit. We conducted univariate and multivariate regression analysis to determine those factors associated with adverse ICU and hospital outcome.

Results

Increases in creatinine as small as 10% (0.2?mg/dl) were associated with prolonged ICU stay (5?days vs 6.6?days, p?<?0.001) and increased mortality (14.6% vs 25.5%, p?<?0.0001). Patients with a 25% rise in creatinine during the first 72?h of ICU admission were twice as likely to die in the hospital (14.3% vs 30.1%, p?<?0.001). RIFLE criteria were accurate predictors of outcome, though they missed much of the risk of even smaller increases in creatinine.

Conclusions

Even small rises in serum creatinine following admission to the ICU are associated with increased morbidity and mortality in oncologic patients. The poor outcome in those with rising creatinine could not be explained by severity of illness or other risk factors. These small changes in creatinine may not be trivial, and should be regarded as evidence of a decline in an individual patient's condition.     

Cerebrospinal fluid pentraxin 3 early after subarachnoid hemorrhage is associated with vasospasm

Purpose

To investigate plasma and cerebrospinal fluid (CSF) concentrations of pentraxin 3 (PTX3), a prototypic long pentraxin protein induced by proinflammatory signals, in subarachnoid hemorrhage (SAH), and its relation with SAH-associated vasospasm.

Methods

Serial plasma and CSF samples were collected from 38 consecutive SAH patients admitted to the Neurosurgical Intensive Care. PTX3 concentrations were analyzed in relation to clinical status and clinical vasospasm (defined as neuro-worsening and angiographic confirmation of vessel narrowing). Since neutrophils are an important source of preformed PTX3, myeloperoxidase (MPO) in CSF was measured to assess the correlation with CSF PTX3 and establish whether blood contamination was the determinant of PTX3 increase.

Results

PTX3 was elevated in all SAH patients both in plasma and CSF. Acute peak (first 48?h after SAH) CSF PTX3 was significantly higher in patients who later developed vasospasm [median 13.6 (range 2.3?C51.9)?ng/ml] compared to those who did not [3.2 (0.1?C50.5)?ng/ml, p?=?0.03]. The temporal pattern of CSF PTX3 in patients with vasospasm was triphasic with a peak during the first 48?h after SAH, a subsequent decrease in the following 48?C96?h and a secondary significant increase with the occurrence of vasospasm. A loose correlation between CSF PTX3 and MPO was observed (r ²?=?0.13), indicating that following SAH there is a brain production of PTX3.

Conclusions

Acute increased concentrations of PTX3 in CSF but not in plasma are related to the occurrence of vasospasm, indicating that measurement of CSF PTX3 associated with the clinical evaluation can improve early diagnosis of this complication.     

Early change in blood glucose concentration is an indicator of mortality in critically ill children

Objective

Hyperglycaemia is associated with increased mortality in critically ill patients. A number of studies have highlighted an association between increased variability of blood glucose (BG) concentration and mortality, supporting a survival disadvantage if BG homeostasis is lost. By exploring the longitudinal BG profile of individual children over time, this study investigates the importance of intact homeostasis early after admission to the paediatric intensive care unit (PICU).

Design, setting, and patients

Retrospective single-centre observational study in a large multi-specialty PICU in the UK. Children admitted between August 2003 and February 2006 were included unless they met exclusion criteria. Data were merged from the PICU clinical database and blood gas analyser database by means of a unique PICU identifier. BG was measured frequently on a blood gas analyser (Bayer Rapidlink). Primary outcome was 100-day mortality. BG parameters were investigated for possible associations with mortality.

Measurements and main results

A total of 1,763 patients were included (median age 1.1?years; IQR 0.1?C5.8). Although admission BG was not associated with mortality, a survival advantage was found in children who showed a reduction in BG on day 1 relative to the admission BG value (p?<?0.001). This remained statistically significant (p?=?0.007) after adjusting for severity of illness.

Conclusions

This study supports an association between early BG profile and mortality in children admitted to PICU, with increased survival in those who demonstrate a fall in BG on day 1 relative to PICU admission. These findings are consistent with a survival advantage of intact BG homeostasis.     

Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study

Introduction

Higher lactate concentrations within the normal reference range (relative hyperlactatemia) are not considered clinically significant. We tested the hypothesis that relative hyperlactatemia is independently associated with an increased risk of hospital death.

Methods

This observational study examined a prospectively obtained intensive care database of 7,155 consecutive critically ill patients admitted to the Intensive Care Units (ICUs) of four Australian university hospitals. We assessed the relationship between ICU admission lactate, maximal lactate and time-weighted lactate levels and hospital outcome in all patients and also in those patients whose lactate concentrations (admission n = 3,964, maximal n = 2,511, and time-weighted n = 4,584) were under 2 mmol.L^-1 (i.e. relative hyperlactatemia).

Results

We obtained 172,723 lactate measurements. Higher admission and time-weightedlactate concentration within the reference range was independently associated with increased hospital mortality (admission odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3 to 3.5, P = 0.01; time-weighted OR 3.7, 95% CI 1.9 to 7.00, P < 0.0001). This significant association was first detectable at lactate concentrations > 0.75 mmol.L^-1. Furthermore, in patients whose lactate ever exceeded 2 mmol.L^-1, higher time-weighted lactate remained strongly associated with higher hospital mortality (OR 4.8, 95% CI 1.8 to 12.4, P < 0.001).

Conclusions

In critically ill patients, relative hyperlactataemia is independently associated with increased hospital mortality. Blood lactate concentrations > 0.75 mmol.L^-1 can be used by clinicians to identify patients at higher risk of death. The current reference range for lactate in the critically ill may need to be re-assessed.     

The early discontinuation of palliative chemotherapy in older patients with cancer

Purpose

Older patients with cancer may have an increased risk of early discontinuation of active treatment (ED), which results in poor outcome in curative or adjuvant settings. We aimed to determine the association between survival and ED and to identify predictors of ED in palliative setting.

Methods

Ninety-eight patients older than 65 years of age who received a comprehensive geriatric assessment (CGA) before palliative first-line chemotherapy were analyzed. Clinical information and CGA results were retrieved from electronic medical record. CGA included Charlson’s co-morbidity index, activities of daily living (ADL), instrumental ADL (IADL), Mini-Mental Status Examination, short-form of the geriatric depression scale, timed-get-up-and-go test (TGUG), and mini-nutritional assessment (MNA). ED was defined as no active cancer treatment (radiotherapy and/or chemotherapy) beyond palliative first-line chemotherapy. Predictors of ED were identified using clinical parameters and CGA.

Results

Active treatment was discontinued after first-line chemotherapy in 30 patients during median follow-up period of 15.1 months. ED after first-line chemotherapy was associated with shorter overall survival (OS; median OS?=?3.1 vs. 14.7 months in patients with ED compared with patients without ED, p?<?0.001). Eastern Cooperative Oncology Group performance status, living alone, ADL, IADL, MNA, and TGUG were associated with ED (p?=?0.001, p?=?0.048, p?=?0.001, p?<?0.001, p?<?0.001, p?=?0.002, respectively). In multivariable analysis, malnutrition and dependent IADL were the independent predictive factors for ED (odds ratio?=?5.03; 95 % confidence interval?=?1.50–16.87: odds ratio?=?3.06; confidence interval?=?1.03–9.12, respectively).

Conclusions

ED was associated with shorter OS in older patients with cancer. Malnutrition and dependent IADL were identified as independent predictive factors for ED.     

Acute kidney injury in critically ill patients with 2009 influenza A (H1N1) viral pneumonia: an observational study

Objective

To describe the incidence, risk factors, and impact on mortality of acute kidney injury (AKI) in patients with 2009 influenza?A (H1N1) viral pneumonia requiring mechanical ventilation.

Design

Observational cohort study.

Patients and methods

AKI was defined as risk, injury or failure, according to the RIFLE classification. Early and late AKI were defined as AKI occurring on intensive care unit (ICU) day?2 or before, or after ICU day?2, respectively. Demographic data and information on organ dysfunction were collected daily.

Results

Of 84 patients, AKI developed in 43 patients (51%). Twenty (24%) needed renal replacement therapy. Early and late AKI were found in 28 (33%) and 15 (18%) patients, respectively. Patients with AKI, as compared with patients without AKI, had higher Acute Physiology and Chronic Health Evaluation (APACHE)?II score and ICU mortality (72% versus 39%, p?<?0.01) and presented on admission more marked cardiovascular, respiratory, and hematological dysfunction. Patients with early but not late AKI presented on admission higher APACHE?II score and more marked organ dysfunction, as compared with patients without AKI. ICU mortality was higher in late versus early AKI (93% versus 61%, p?<?0.001). On multivariate analysis, only APACHE?II score and late but not early AKI [odds ratio (OR) 1.1 (95% confidence interval 1.0?C1.1) and 15.1 (1.8?C130.7), respectively] were associated with mortality.

Conclusions

AKI is a frequent complication of 2009 influenza?A (H1N1) viral pneumonia. AKI developing after 2?days in ICU appears to be associated with different risk factors than early AKI, and is related to a higher mortality rate.     

Lung water assessment by lung ultrasonography in intensive care: a pilot study

Objective

To investigate the accuracy of lung ultrasonography (LUS) in the quantification of lung water in critically ill patients by using quantitative computed tomography (CT) as the gold standard for the determination of lung weight.

Methods

Twenty consecutive patients admitted to an intensive care unit who underwent chest CT as a step in their clinical management were evaluated within 4?h by LUS. Lung weight, lung volume, and physical lung density were calculated from the CT scans using ad hoc software. Semiquantitative ultrasound assessment of lung water was performed by determining the ultrasound B-line score, defined as the total number of B-lines detectable in an anterolateral LUS examination.

Results

Good correlations were found between the B-line score and lung weight (r?=?0.75, p?<?0.05) and density (r?=?0.82, p?<?0.01), that only marginally increased when the lung density of the first 10?mm of subpleural lung tissue was evaluated (r?=?0.83, p?<?0.01). Moreover, values of subpleural lung density were not significantly different from values of the whole lung density (0.34?±?0.11 vs. 0.37?±?0.16?g/ml, p?=?ns). Very good correlations were found between the B-line score and both the weight (r?=?0.85, p?<?0.01) and the density (r?=?0.88, p?<?0.01) of the upper lobes. The weight of the lower lobes was not correlated with the B-line score (r?=?0.14, p?=?ns).

Conclusions

Lung ultrasound B-lines are correlated with lung weight and density determined by CT. LUS may provide a reliable, simple and radiation-free lung densitometry in the intensive care setting.     

Health-related outcomes of critically ill patients with and without sepsis

Purpose

To determine differences in health-related quality of life (HRQoL), survival and healthcare resource use of critically ill adults with and without sepsis.

Methods

We conducted a primary propensity score matched analysis of patients with and without sepsis enrolled in a large multicentre clinical trial. Outcomes included HRQoL at 6 months, survival to 2 years, length of ICU and hospital admission and cost of ICU and hospital treatment to 2 years.

Results

We obtained linked data for 3442 (97.3%) of 3537 eligible patients and matched 806/905 (89.0%) patients with sepsis with 806/2537 (31.7%) without. After matching, there were no significant differences in the proportion of survivors with and without sepsis reporting problems with mobility (37.8% vs. 38.7%, p?=?0.86), self-care (24.7% vs. 26.0%, p?=?0.44), usual activities (44.5% vs. 46.8%, p?=?0.28), pain/discomfort (42.4% vs. 41.6%, p?=?0.54) and anxiety/depression (36.9% vs. 37.7%, p?=?0.68). There was no significant difference in survival at 2 years: 482/792 (60.9%) vs. 485/799 (60.7%) (HR 1.01, 95% CI 0.86–1.18, p?=?0.94). The initial ICU and hospital admission were longer for patients with sepsis: 10.1?±?11.9 vs. 8.0?±?9.8 days (p?<?0.0001) and 22.8?±?21.2 vs. 19.1?±?19.0 days, (p?=?0.0003) respectively. The cost of ICU admissions was higher for patients with sepsis: A$43,345?±?46,263 (€35,109?±?35,043) versus 34,844?±?38,281 (€28,223?±?31,007), mean difference $8501 (€6885), 95% CI $4342–12,660 (€3517?±?10,254), p?<?0.001 as was the total cost of hospital treatment to 2 years: A$74,120?±?60,750 (€60,037?±?49,207) versus A$65,806?±?59,856 (€53,302?±?48,483), p?=?0.005.

Conclusions

Critically ill patients with sepsis have higher healthcare resource use and costs but similar survival and HRQoL compared to matched patients without sepsis.

     

Adverse effects of permanent atrial fibrillation on heart failure in patients with preserved left ventricular function and chronic right apical pacing for complete heart block

Background

The impact of atrial fibrillation (AF) on heart failure (HF) was evaluated in patients with preserved left ventricular (LV) function and long-term right ventricular (RV) pacing for complete heart block.

Methods

Clinical, echocardiographic, and laboratory parameters of HF were assessed in 35 patients with established AF who had undergone ablation of the atrioventricular node and pacemaker implantation (Group A) and 31 patients who received dual-chamber pacing for spontaneous complete heart block (Group B).

Results

During a follow-up period of 12.7?±?7.5?years, New York Heart Association (NYHA) functional class increased from 1.3?±?0.5 to 2.1?±?0.6 (p?p?p?p?=?0,21) in Group B. At the end of follow-up, markers of LV function were moderately depressed in Group A compared with those in Group B: NYHA class 2.1?±?0.6 versus 1.6?±?0.7, p?=?0.001; LVEF 53.0?±?8.2 versus 56.9?±?7.0?%, p?p?p?10?%, increasing NYHA class ≥1, and NT-proBNP levels >1,000?pg/ml.

Conclusions

Permanent AF was associated with adverse effects on LV function and symptoms of HF in patients with long-term RV pacing for complete heart block, and appears to play an important role in the development of HF in this specific patient cohort.     

Characteristics and determinants of outcome of hospital-acquired bloodstream infections in intensive care units: the EUROBACT International Cohort Study

Purpose

The recent increase in drug-resistant micro-organisms complicates the management of hospital-acquired bloodstream infections (HA-BSIs). We investigated the epidemiology of HA-BSI and evaluated the impact of drug resistance on outcomes of critically ill patients, controlling for patient characteristics and infection management.

Methods

A prospective, multicentre non-representative cohort study was conducted in 162 intensive care units (ICUs) in 24 countries.

Results

We included 1,156 patients [mean?±?standard deviation (SD) age, 59.5?±?17.7?years; 65?% males; mean?±?SD Simplified Acute Physiology Score (SAPS)?II score, 50?±?17] with HA-BSIs, of which 76?% were ICU-acquired. Median time to diagnosis was 14 [interquartile range (IQR), 7–26] days after hospital admission. Polymicrobial infections accounted for 12?% of cases. Among monomicrobial infections, 58.3?% were gram-negative, 32.8?% gram-positive, 7.8?% fungal and 1.2?% due to strict anaerobes. Overall, 629 (47.8?%) isolates were multidrug-resistant (MDR), including 270 (20.5?%) extensively resistant (XDR), and 5 (0.4?%) pan-drug-resistant (PDR). Micro-organism distribution and MDR occurrence varied significantly (p?<?0.001) by country. The 28-day all-cause fatality rate was 36?%. In the multivariable model including micro-organism, patient and centre variables, independent predictors of 28-day mortality included MDR isolate [odds ratio (OR), 1.49; 95?% confidence interval (95?%CI), 1.07–2.06], uncontrolled infection source (OR, 5.86; 95?%CI, 2.5–13.9) and timing to adequate treatment (before day?6 since blood culture collection versus never, OR, 0.38; 95?%CI, 0.23–0.63; since day?6 versus never, OR, 0.20; 95?%CI, 0.08–0.47).

Conclusions

MDR and XDR bacteria (especially gram-negative) are common in HA-BSIs in critically ill patients and are associated with increased 28-day mortality. Intensified efforts to prevent HA-BSIs and to optimize their management through adequate source control and antibiotic therapy are needed to improve outcomes.     

AV interval optimization using pressure volume loops in dual chamber pacemaker patients with maintained systolic left ventricular function

Background

Atrioventricular (AV) interval optimization is often deemed too time-consuming in dual-chamber pacemaker patients with maintained LV function. Thus the majority of patients are left at their default AV interval.

Objective

To quantify the magnitude of hemodynamic improvement following AV interval optimization in chronically paced dual chamber pacemaker patients.

Patients and methods

A pressure volume catheter was placed in the left ventricle of 19 patients with chronic dual chamber pacing and an ejection fraction >45?% undergoing elective coronary angiography. AV interval was varied in 10?ms steps from 80 to 300?ms, and pressure volume loops were recorded during breath hold.

Results

The average optimal AV interval was 152?±?39?ms compared to 155?±?8?ms for the average default AV interval (range 100–240?ms). The average improvement in stroke work following AV interval optimization was 935?±?760?mmHg/ml (range 0–2,908; p?p?=?0.01).

Conclusion

The overall hemodynamic effect of AV interval optimization in patients with maintained LV function is in the same range as for patients undergoing cardiac resynchronization therapy for several parameters. The positive effect of AV interval optimization also applies to patients who have been chronically paced for years.     

Impact of hypoxic hepatitis on mortality in the intensive care unit

Purpose

Hypoxic hepatitis (HH) is a form of hepatic injury following arterial hypoxemia, ischemia, and passive congestion of the liver. We investigated the incidence and the prognostic implications of HH in the medical intensive care unit (ICU).

Methods

A total of 1,066 consecutive ICU admissions at three medical ICUs of a university hospital were included in this prospective cohort study. All patients were screened prospectively for the presence of HH according to established criteria. Independent risk factors of mortality in this cohort of critically ill patients were identified by a multivariate Poisson regression model.

Results

A total of 118 admissions (11%) had HH during their ICU stay. These patients had different baseline characteristics, longer median ICU stay (8 vs. 6?days, p?p?p?p?p?=?0.359).

Conclusions

Hypoxic hepatitis (HH) occurs frequently in the medical ICU. The presence of HH is a strong risk factor for mortality in the ICU in patients requiring vasopressor therapy.     

Improved short- and long-term outcome of allogeneic stem cell recipients admitted to the intensive care unit: a retrospective longitudinal analysis of 942 patients

Purpose

Intensive care unit (ICU) admission of allogeneic hematopoietic stem cell transplant (HSCT) recipients is associated with relatively poor outcome. Since longitudinal data on this topic remains scarce, we analyzed reasons for ICU admission as well as short- and long-term outcome of critically ill HSCT recipients.

Methods

A total of 942 consecutive adult patients were transplanted at Hannover Medical School from 2000 to 2013. Of those, 330 patients were at least admitted once to the ICU and included in this retrospective study. To analyze time-dependent improvements, we separately compared patient characteristics as well as reasons and outcome of ICU admission for the periods 2000–2006 and 2007–2013.

Results

The main reasons for ICU admission were acute respiratory failure (ARF) in 35%, severe sepsis/septic shock in 23%, and cardiac problems in 18%. ICU admission was clearly associated with shortened survival (p?<?0.001), but survival of ICU patients after hospital discharge reached 44% up to 5 years and was comparable to that of non-ICU HSCT patients. When ICU admission periods were compared, patients were older (48 vs. 52 years; p?<?0.005) and the percentage of ARF as leading cause for ICU admission decreased from 43% in the first to 30% in the second period. Over time ICU and hospital survival improved from 44 to 60% (p?<?0.01) and from 26 to 43% (p?<?0.01), respectively. The 1- and 3-year survival rate after ICU admission increased significantly from 14 to 32% and from 11 to 23% (p?<?0.01).

Conclusions

Besides ARF and septic shock, cardiac events were especially a major reason for ICU admission. Both short- and long-term survival of critically ill HSCT patients has improved significantly in recent years, and survival of HSCT recipients discharged from hospital is not significantly affected by a former ICU stay.

     

The use of end-tidal carbon dioxide monitoring in patients with hypotension in the emergency department

Background

The aim of this study was to determine the usefulness of end tidal carbon dioxide (ETCO₂) monitoring in hypotensive shock patients presenting to the ED.

Methods

This was a prospective observational study in a tertiary ED. One hundred three adults in shock with hypotension presenting to the ED were recruited into the study. They were grouped according to different types of shock, hypovolemic, cardiogenic, septic and others. Vital signs and ETCO₂ were measured on presentation and at 30-min intervals up to 120 min. Blood gases and serum lactate levels were obtained on arrival. All patients were managed according to standard protocols and treatment regimes. Patient survival up to hospital admission and at 30 days was recorded.

Results

Mean ETCO₂ for all patients on arrival was 29.07?±?9.96 mmHg. Average ETCO₂ for patients in hypovolemic, cardiogenic and septic shock was 29.64?±?11.49, 28.60?±?9.87 and 27.81?±?7.39 mmHg, respectively. ETCO₂ on arrival was positively correlated with systolic and diastolic BP, MAP, bicarbonate, base excess and lactate when analyzed in all shock patients. Early ETCO₂ measurements were found to be significantly lower in patients who did not survive to hospital admission (p?=?0.005). All patients who had ETCO₂????12mmHg died in the ED. However, normal ETCO₂ does not ensure patient survival.

Conclusion

The use of ETCO₂ in the ED has great potential to be used as a method of non-invasive monitoring of patients in shock.