Low serum albumin levels and new-onset atrial fibrillation in the ICU: a prospective cohort study

PurposeThe aim was to determine if a low serum albumin (SA) level was associated with the occurrence of new onset atrial fibrillation (NOAF) during the first 48 h of intensive care unit (ICU) admission.MethodsOverall, 97 patients admitted to the ICU were included in this prospective study. NOAF during the first 48 h was defined as irregularity and absence of p-waves on the continuous electrocardiogram, lasting longer than 2 min. Association were analysed using logistic regression with correction for confounding variables in multivariable analysis.ResultsThe incidence of NOAF during the first 48 h of ICU admission was 18%. SA levels at ICU admission were significantly associated with NOAF after correction for confounders (odds ratio [OR] 0.86, 95%CI 0.77–0.97, p = .010). SA levels were also significantly associated with the number of episodes of NOAF in multivariate analysis (−0.09 episodes, 95%CI [−0.15/−0.04], p = .001), but not with the presence of sinus rhythm at 48 h (OR 1.05, 95%CI [0.93–1.12], p = .46).ConclusionIn this small hypothesis generating study low levels of SA were associated with the occurrence of NOAF. It remains to be shown if increasing SA levels lowers the incidence of NOAF.     

Epidemiology and outcome of new-onset atrial fibrillation in the medical intensive care unit

ObjectiveTo assess the incidence of new-onset atrial fibrillation (NOAF) in the medical intensive care unit setting and describe associated characteristics and implications for long-term outcomes.Materials and MethodsA single-center, retrospective study of patients admitted to a medical intensive care unit from January 1, 2008, to December 31, 2013, was conducted. Atrial fibrillation (AF) diagnosis was categorized as NOAF or preexisting (PEAF). Intensive care unit characteristics along with in-hospital and long-term outcomes were compared.ResultsA total of 10, 836 patients were included, 582 (5%) with NOAF, 2368 (22%) with PEAF, and 7886 (73%) with non-AF. Adjusted ICU management differed (P< .001) between all groups (NOAF vs PEAF vs non-AF) in regard to incidence of vasopressor use, mechanical ventilation, and renal replacement therapy, occurring more frequently in NOAF. Although ICU mortality was greater for NOAF (odds ratio, 1.40; 95% confidence interval, 1.03-1.87; P= .03), NOAF was not predictive of in-hospital mortality after adjustment for greater disease severity. One-year survival after ICU discharge was similar for both AF groups when compared with non-AF (54%, 52%, 75%; P< .001, log-rank).ConclusionsRisk factors for AF were less common in NOAF than in PEAF, yet NOAF incidence was associated with greater ICU disease severity and poorer short-term ICU outcomes. New-onset AF was not independently predictive of in-hospital mortality.     

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.     

Impact of increased calls to rapid response systems on unplanned ICU admission

BackgroundWhether hospital bed number and rapid response system (RRS) call rate is associated with the clinical outcomes of patients who have RRS activations is unknown. We test a hypothesis that hospital volume and RRS call rates are associated with the clinical outcomes of patients with RRSs.MethodsThis is a retrospective chart analysis of an existing dataset associated with In-Hospital Emergency Registry in Japan. In the present study, 4818 patients in 24 hospitals from April 2014 to March 2018 were analyzed. Primary outcome variable was an unplanned intensive care unit (ICU) admission after RRS activation.ResultsIn the primary analysis of the study using a multivariate analysis adjusting potential confounding factors, higher RRS call rate was significantly associated with decreased unplanned ICU admissions (P < 0.0001, Odds ratio [OR] 0.95, 95% confidence interval [CI] 0.92–0.98), but there was no significant association of hospital volume with unplanned ICU admissions (P = 0.44). In the secondary analysis of the study, there was a non-significant trend of increased cardiac arrest on arrival at the location of the RRS provider at large-volume hospitals (P = 0.084, OR 1.16, 95% CI 0.98–1.38). Large-volume hospitals had a significantly higher 1-month mortality rate (P = 0.0040, OR 1.10, 95% CI 1.03–1.18).ConclusionHospitals with increased RRS call rates had significantly decreased unplanned ICU admission in patients who had RRS activations. Patients who had RRS activations at large-volume hospitals had an increased 1-month mortality rate.     

Impact of early ICU admission for critically ill cancer patients: Post-hoc analysis of a prospective multicenter multinational dataset.

ObjectivesEarly intensive care unit (ICU) admission, in Critically Ill Cancer Patients (CICP), is believed to have contributed to the prognostic improvement of critically ill cancer patients. The primary objective of this study was to assess the association between early ICU admission and hospital mortality in CICP.DesignRetrospective analysis of a prospective multicenter dataset. Early admission was defined as admission in the ICU < 24 h of hospital admission. We assessed the association between early ICU admission and hospital mortality in CICP via survival analysis and propensity score matching.ResultsOf the 1011patients in our cohort, 1005 had data available regarding ICU admission timing and were included. Overall, early ICU admission occurred in 455 patients (45.3%). Crude hospital mortality in patients with early and delayed ICU admission was 33.6% (n = 153) vs. 43.1% (n = 237), respectively (P = 0.02). After adjustment for confounders, early compared to late ICU admission was not associated with hospital mortality (HR 0.92; 95%CI 0.76–1.11). After propensity score matching, hospital mortality did not differ between patients with early (35.2%) and late (40.6%) ICU admission (P = 0.13). In the matched cohort, early ICU admission was not associated with mortality after adjustment on SOFA score (HR 0.89; 95%CI 0.71–1.12). Similar results were obtained after adjustment for center effect.ConclusionIn this cohort, early ICU admission was not associated with a better outcome after adjustment for confounder and center effect. The uncertainty with regard to the beneficial effect of early ICU on hospital mortality suggests the need for an interventional study.     

Associations between hospital occupancy,intensive care unit transfer delay and hospital mortality

PurposeHospital occupancy (HospOcc) pressures often lead to longer intensive care unit (ICU) stay after physician recognition of discharge readiness. We evaluated the relationships between HospOcc, extended ICU stay, and patient outcomes.Materials and methods7-year retrospective cohort study of 8500 alive discharge encounters from 4 adult ICUs of a tertiary hospital. We estimated associations between i) HospOcc and ICU transfer delay; and ii) ICU transfer delay and hospital mortality.ResultsMedian (IQR) ICU transfer delay was 4.8 h (1.6–11.7), 1.4% (119) suffered in-hospital death, and 4% (341) were readmitted. HospOcc was non-linearly related with ICU transfer delay, with a spline knot at 80% (mean transfer delay 8.8 h [95% CI: 8.24, 9.38]). Higher HospOcc level above 80% was associated with longer transfer delays, (mean increase 5.4% per % HospOcc increase; 95% CI, 4.7 to 6.1; P < .001). Longer ICU transfer delay was associated with increasing odds of in-hospital death or ICU readmission (odds ratio 1.01 per hour; 95% CI 1.00 to 1.01; P = .04) but not with ICU readmission alone (OR 1.01 per hour; 95% CI 1.00 to 1.01, P = .14).ConclusionsICU transfer delay exponentially increased above a threshold hospital occupancy and may be associated with increased hospital mortality.     

Association between pre-intensive care unit (ICU) hospital length of stay and ICU outcomes in a resource-limited setting

Background Previous studies demonstrated higher mortality for patients with a longer pre-intensive care unit (ICU) hospital length of stay (LOS), in well-resourced settings. Objectives The study aimed to determine the association between pre-ICU hospital LOS and ICU outcomes in a resource-limited setting. We hypothesised that longer pre-ICU hospital LOS would be associated with higher ICU mortality. Methods This was a retrospective cohort study measuring the association between pre-ICU hospital LOS and ICU outcomes using data extracted from a regional hospital ICU in KwaZulu-Natal, South Africa. Consecutive ICU admissions of all patients (medical and surgical) older than 18 years were included during the study period September 2014 to August 2018. A corrected sample size of 2 040 patients was identified. Multivariable logistic regression was used to assess the primary outcome of ICU mortality, and multivariable Cox proportional hazard regression was used for the secondary outcome of ICU LOS. Results The median pre-ICU hospital LOS was 1 day (interquartile range (IQR) 0 - 2 days). The median length of ICU stay was 2.4 days (IQR 1.1 - 4.8 days) and the observed ICU mortality was 16% (n=327/2 040). Pre-ICU hospital LOS was not associated with ICU mortality in the unadjusted (odds ratio (OR) 1.00; 95% confidence interval (CI) 0.98 - 1.02; p=0.68; n=2 040) and fully adjusted logistic regression models (OR 1.00; 95% CI 0.98 - 1.03; p=0.90; n=1 981) using a complete case analysis for missing patient-level covariates. In Cox proportional hazard models, there was no association between pre-ICU hospital LOS and ICU LOS (hazard ratio 1.00; 95% CI 0.98 - 1.03; p=0.72; n=1 967), including when stratified by admission source. Conclusion Pre-ICU hospital LOS was not associated with either ICU mortality or ICU LOS in a resource-limited setting. Future studies should aim to include multicentre data and evaluate long-term outcomes. Contributions of the study The study was conducted in a resource-limited setting and found no association between prolonged LOS pre-ICU and patient outcomes. Several potential explanations for this observation have been explored. This important subject is pertinent to the appropriate use of limited resources and encourages future studies to evaluate this association and to consider longer-term outcomes (e.g. 30-day mortality) in future findings.     

The Surgical Optimal Mobility Score predicts mortality and length of stay in an Italian population of medical,surgical, and neurologic intensive care unit patients

PurposeWe validated the Italian version of Surgical Optimal Mobility Score (SOMS) and evaluated its ability to predict intensive care unit (ICU) and hospital length of stay (LOS), and hospital mortality in a mixed population of ICU patients.Materials and MethodsWe applied the Italian version of SOMS in a consecutive series of prospectively enrolled, adult ICU patients. Surgical Optimal Mobility Score level was assessed twice a day by ICU nurses and twice a week by an expert mobility team. Zero-truncated Poisson regression was used to identify predictors for ICU and hospital LOS, and logistic regression for hospital mortality. All models were adjusted for potential confounders.ResultsOf 98 patients recruited, 19 (19.4%) died in hospital, of whom 17 without and 2 with improved mobility level achieved during the ICU stay. SOMS improvement was independently associated with lower hospital mortality (odds ratio, 0.07; 95% confidence interval [CI], 0.01-0.42) but increased hospital LOS (odds ratio, 1.21; 95% CI: 1.10-1.33). A higher first-morning SOMS on ICU admission, indicating better mobility, was associated with lower ICU and hospital LOS (rate ratios, 0.89 [95% CI, 0.80-0.99] and 0.84 [95% CI, 0.79-0.89], respectively).ConclusionsThe first-morning SOMS on ICU admission predicted ICU and hospital LOS in a mixed population of ICU patients. SOMS improvement was associated with reduced hospital mortality but increased hospital LOS, suggesting the need of optimizing hospital trajectories after ICU discharge.     

Trends in opioid use before critical illness among elderly patients in Ontario

PurposeTo assess temporal trends in pre-existing opioid exposure prior to hospitalization among elderly intensive care unit (ICU) patients and its association with adverse outcomes.Materials and methodsWe performed a population-based retrospective cohort study using health administrative data from the province of Ontario, Canada. We included all older adult (> 65 years) admissions to an ICU between April 2002 and March 2015. The exposure was opioid use before admission categorized as chronic use, intermittent use, and non-use.ResultsThe cohort included 711,312 elderly patient admissions to an ICU. Of these, 6.8% (n = 48,363) were chronic opioid users, 28.1% (n = 200,149) intermittent users, and 65.0% (n = 462,800) non-users. Compared with non-users, chronic opioid users and intermittent users had higher in-hospital mortality (adjusted odds ratio: 1.12, 95% CI, 1.09–1.15, p < 0.0001 for chronic users; adjusted odds ratio: 1.09, 95% CI, 1.07–1.11, p < 0.0001 for intermittent users), and a lower subdistribution hazard of time to hospital discharge, translating to a longer hospital length of stay (adjusted hazard ratio: 0.87, 95% CI, 0.85–0.88, p < 0.0001 for chronic users; adjusted hazard ratio: 0.93, 95% CI, 0.92–0.94, p < 0.0001 for intermittent users).ConclusionsAmong elderly ICU patients, opioid exposure prior to admission is prevalent and use is associated with higher in-hospital mortality.     

Effect of rapid fluid administration on the prognosis of septic shock patients with isolated hyperlactatemia: A prospective multicenter observational study

BackgroundWe aimed to investigate the association between initial fluid resuscitation in septic shock patients with isolated hyperlactatemia and outcomes.MethodsThis multicenter prospective study was conducted using the data from the Korean Shock Society registry. Patients diagnosed with isolated hyperlactatemia between October 2015 and December 2018 were included and divided into those who received 30 mL/kg of fluid within 3 or 6 h and those who did not receive. The primary outcome was in-hospital mortality; the secondary outcomes were intensive care unit (ICU) admission, length of ICU stay, mechanical ventilation, and renal replacement therapy (RRT).ResultsA total of 608 patients were included in our analysis. The administration of 30 mL/kg crystalloid within 3 or 6 h was not significantly associated with in-hospital mortality in multivariable logistic regression analysis ([OR, 0.8; 95% CI, 0.52–1.23, p = 0.31], [OR, 0.96; 95% CI, 0.59–1.57, p = 0.88], respectively). The administration of 30 mL/kg crystalloid within 3-h was not significantly associated with mechanical ventilation and RRT ([OR, 1.19; 95% CI, 0.77–1.84, p = 0.44], [OR, 1.2; 95% CI, 0.7–2.04, p = 0.5], respectively). However, the administration of 30 mL/kg crystalloid within 6 h was associated with higher ICU admission and RRT ([OR, 1.57; 95% CI, 1.07–2.28, p = 0.02], [OR, 2.08; 95% CI, 1.19–3.66, p = 0.01], respectively).ConclusionsInitial fluid resuscitation of 30 mL/kg within 3 or 6 h was neither associated with an increased or decreased in-hospital mortality in septic shock patients with isolated hyperlactatemia.     

Risk Factors for New Onset Atrial Fibrillation during Thyroid Gland Surgery

ObjectiveThyroid dysfunction is a common cause of atrial fibrillation (AF). Incidence of AF is high in patients with both expressed and subclinical hyperthyroidism. The aim of our study was to determine the incidence and predictors of new onset atrial fibrillation (NOAF) in euthyroid patients undergoing thyroid surgery.Subject and MethodsThe study included 1,252 euthyroid patients with American Society of Anesthesiologists (ASA) physical status ASA 2 and ASA 3, who were 18 years and older and were in sinus rhythm. Patients without comorbidity and patients with persistent AF were excluded. We investigated the influence of the following preoperative characteristics on the occurrence of NOAF: age, sex, body mass index, ASA score, admission diagnoses, and comorbidity. We noted the influence of difficult intubation of trachea, type and duration of surgery, and time under general anaesthesia. Univariate and multivariate logistic regression were used to determine predictors of occurrence of NOAF.ResultsNOAF was noted in 0.72% of patients. Patients with NOAF were older (63.11 vs. 56.81 years) than patients without NOAF, but this was not statistically significant. Significantly more patients from the NOAF group had preoperative heart rhythm disturbance and a history of angina pectoris, in contrast to patients without registered NOAF (p = 0.001; p = 0.017). Multivariate analysis showed that a history of heart rhythm disturbance was an independent predictor of NOAF.ConclusionsIncidence of NOAF during thyroid surgery is similar to the other type of surgery, if the values of thyroid hormones are normal.     

Annual prevalence,characteristics, and outcomes of intensive care patients with skin or soft tissue infections in Australia and New Zealand: A retrospective cohort study between 2006-2017

BackgroundThere are limited published data on the epidemiology of skin and soft tissue infections (SSTIs) requiring intensive care unit (ICU) admission. This study intended to describe the annual prevalence, characteristics, and outcomes of critically ill adult patients admitted to the ICU for an SSTI.MethodsThis was a registry-based retrospective cohort study, using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database for all admissions with SSTI between 2006 and 2017. The inclusion criteria were as follows: primary diagnosis of SSTI and age ≥16 years. The exclusion criteria were as follows: ICU readmissions (during the same hospital admission) and transfers from ICUs from other hospitals. The primary outcome was in-hospital mortality, and the secondary outcomes were ICU mortality and length of stay (LOS) in the ICU and hospital with independent predictors of outcomes.ResultsAdmissions due to SSTI accounted for 10 962 (0.7%) of 1 470 197 ICU admissions between 2006 and 2017. Comorbidities were present in 25.2% of the study sample. The in-hospital mortality was 9% (991/10 962), and SSTI necessitating ICU admission accounted for 0.07% of in-hospital mortality of all ICU admissions between 2006 and 2017. Annual prevalence of ICU admissions for SSTI increased from 0.4% to 0.9% during the study period, but in-hospital mortality decreased from 16.1% to 6.8%. The median ICU LOS was 2.1 days (interquartile range = 3.4), and the median hospital LOS was 12.1 days (interquartile range = 20.6). ICU LOS remained stable between 2006 and 2017 (2.0–2.1 days), whereas hospital LOS decreased from 15.7 to 11.2 days. Predictors for in-hospital mortality included Australian and New Zealand Risk of Death scores [odds ratio (OR): 1.07; confidence interval (CI) (1.05, 1.09); p < 0.001], any comorbidity except diabetes [OR: 2.00; CI (1.05, 3.79); p = 0.035], and admission through an emergency response call [OR: 2.07; CI (1.03, 4.16); p = 0.041].ConclusionsSSTIs are uncommon as primary ICU admission diagnosis. Although the annual prevalence of ICU admissions for SSTI has increased, in-hospital mortality and hospital LOS have decreased over the last decade.     

Phosphate abnormalities and outcomes among admissions to the intensive care unit: A retrospective multicentre cohort study

PurposeWe investigated the effect of serum phosphate abnormalities at intensive care unit (ICU) admission on risk of death and length of stay in critically ill patients.Materials and methodsA retrospective cohort of patients admitted to three adult ICUs in Queensland, Australia from April 2014 to 2019 was studied. Hypophosphataemia, normophosphataemia and hyperphosphataemia were defined as serum phosphate level of <0.8, 0.8–1.5 and >1.5 mmol/L respectively. Univariable and logistic regression analyses were performed to investigate the association between the phosphate groups and the risk of death.Measurements and main resultsWe included 13,155 patients in the analysis, of which 1424 (10.8%) patients had hypophosphataemia and 2544 (19.3%) hyperphosphataemia. The mean admission phosphate level was 1.25 (SD, ±0.43) mmol/L. Both hypophosphatemia (OR 1.29; 95% CI, 1.02–1.64; p = 0.034) and hyperphosphataemia (OR 1.39; 95% CI, 1.15–1.68; p = 0.001) at admission were independently associated with increased risk of death after adjusting for covariables using logistic regression analysis.ConclusionHypophosphatemia and hyperphosphatemia were both independently associated with an increased case fatality rate and ICU length of stay in a large multicentre ICU cohort.     

Association Between Achieving Inpatient Glycemic Control and Clinical Outcomes in Hospitalized Patients With COVID-19: A Multicenter,Retrospective Hospital-Based Analysis

OBJECTIVEDiabetes and hyperglycemia are important risk factors for poor outcomes in hospitalized patients with coronavirus disease 2019 (COVID-19). We hypothesized that achieving glycemic control soon after admission, in both intensive care unit (ICU) and non-ICU settings, could affect outcomes in patients with COVID-19.RESEARCH DESIGN AND METHODSWe analyzed pooled data from the Glytec national database including 1,544 patients with COVID-19 from 91 hospitals in 12 states. Patients were stratified according to achieved mean glucose category in mg/dL (≤7.77, 7.83–10, 10.1–13.88, and >13.88 mmol/L; ≤140, 141–180, 181–250, and >250 mg/dL) during days 2–3 in non-ICU patients or on day 2 in ICU patients. We conducted a survival analysis to determine the association between glucose category and hospital mortality.RESULTSOverall, 18.1% (279/1,544) of patients died in the hospital. In non-ICU patients, severe hyperglycemia (blood glucose [BG] >13.88 mmol/L [250 mg/dL]) on days 2–3 was independently associated with high mortality (adjusted hazard ratio [HR] 7.17; 95% CI 2.62–19.62) compared with patients with BG <7.77 mmol/L (140 mg/dL). This relationship was not significant for admission glucose (HR 1.465; 95% CI 0.683–3.143). In patients admitted directly to the ICU, severe hyperglycemia on admission was associated with increased mortality (adjusted HR 3.14; 95% CI 1.44–6.88). This relationship was not significant on day 2 (HR 1.40; 95% CI 0.53–3.69). Hypoglycemia (BG <70 mg/dL) was also associated with increased mortality (odds ratio 2.2; 95% CI 1.35–3.60).CONCLUSIONSBoth hyperglycemia and hypoglycemia were associated with poor outcomes in patients with COVID-19. Admission glucose was a strong predictor of death among patients directly admitted to the ICU. Severe hyperglycemia after admission was a strong predictor of death among non-ICU patients.     

A comparative analysis of the outcomes of patients with influenza or COVID-19 in a tertiary hospital in Belgium

IntroductionThe COVID-19 pandemic has emerged as a global health problem, associated with high morbidity and mortality rates. The aim of this study was to compare the outcomes of hospitalized patients with COVID-19 or with seasonal influenza in a teaching hospital in Belgium.MethodsIn this retrospective, single-center cohort study, 1384 patients with COVID-19 and 226 patients with influenza were matched using a propensity score with a ratio of 3:1. Primary outcomes included admission to intensive care unit (ICU), intubation rates, hospital length of stay, readmissions within 30 days and in-hospital mortality. Secondary outcomes included pulmonary bacterial superinfection, cardiovascular complications and ECMO.ResultsBased on the analysis of the matched sample, patients with influenza had an increased risk of readmission within 30 days (Risk Difference (RD): 0.07, 95% CI: 0.03 to 0.11) and admission to intensive care unit (RD: 0.09, 95% CI: 0.03 to 0.15) compared with those with COVID-19. Patients with influenza had also more pulmonary bacterial superinfections (46.2% vs 7.4%) and more cardiovascular complications (32% vs 3.9%) than patients with COVID-19.However, a two-fold increased risk of mortality (RD: ?0.10, 95% CI: 0.15 to ?0.05) was observed in COVID-19 compared to influenza. ECMO was also more required among the COVID-19 patients who died than among influenza patients (5% vs 0%).ConclusionsCOVID-19 is associated with a higher in-hospital mortality compared to influenza infection, despite a high rate of ICU admission in the influenza group. These findings highlighted that the severity of hospitalized patients with influenza should not be underestimated.     

Healthcare utilization and mortality outcomes in patients with pre-existing psychiatric disorders after intensive care unit discharge: A population-based retrospective cohort study

PurposePre-existing psychiatric disorders may lead to negative outcomes following intensive care unit (ICU) discharge. We evaluated the association of pre-existing psychiatric disorders with subsequent healthcare utilization and mortality in patients discharged from ICU.Materials and methodsWe retrospectively studied adult patients admitted to 14 medical-surgical ICUs (January 2014–June 2016) with ICU length stay ≥24 h who survived to hospital discharge. Pre-existing psychiatric disorders were identified using algorithms for diagnostic codes captured ≤5 years before ICU admission. Outcomes were healthcare utilization (emergency department visit, hospital or ICU readmission) and mortality. We used logistic regression models with propensity scores to estimate associations, converted to risk ratios (RR).ResultsWe included 10,598 patients. 37.6% (n = 3982) had a psychiatric history. Patients with pre-existing psychiatric disorders were at higher risk of subsequent emergency department visits (RR 1.49, 95%CI 1.29–1.71), hospital readmission (RR 1.49, 95%CI 1.34–1.66), ICU readmission (RR 2.64, 95%CI 1.55–4.49) one-year post-ICU discharge, compared to patients without pre-existing psychiatric disorders. Patients with pre-existing psychiatric disorders had a higher risk of mortality (RR 1.31, 95%CI 1.00–1.71) six-months post-ICU discharge.ConclusionCritically ill patients with pre-existing psychiatric disorders have an increased risk of healthcare utilization and mortality outcomes following an ICU stay.     

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.     

A novel predictive tool for prognosis in elderly patients with urinary tract infection: Modified PRACTICE

PurposeWe evaluated whether combining the serum albumin level and the Prediction Rule for Admission policy in Complicated urinary Tract InfeCtion LEiden (PRACTICE) class could be a prognostic predictor in elderly patients with urinary tract infection (UTI).MethodsWe retrospectively included adult patients (age ≥ 65 years) with UTI who were hospitalized in the emergency department (ED) between January 1, 2014 and December 31, 2018. We graded the serum albumin level and classified the PRACTICE score; the modified PRACTICE was defined as the sum of the albumin level grade and the PRACTICE class. We comparatively assessed the predictive value for in-hospital mortality and admission to the intensive care unit (ICU) in survivor and non-survivor groups.ResultsIn total, the study analysis included 1159 patients, and in-hospital mortality was 3.4% (n = 39). The modified PRACTICE score (4.0 [1.4] vs 6.1 [1.2], p < 0.001) was significantly increased in the non-survivor group. The area under the curve value of factors associated with in-hospital mortality were the Modified Early Warning Score (MEWS) 0.57 (95% CI 0.54–0.60), albumin 0.83 (95% CI 0.81–0.85), PRACTICE 0.71 (95% CI 0.69–0.74), and the modified PRACTICE 0.86 (95% CI 0.84–0.88). Factors associated with ICU admission were MEWS 0.65 (95% CI 0.62–0.68), albumin 0.66 (95% CI 0.64–0.69), PRACTICE 0.66 (95% CI 0.63–0.68), and the modified PRACTICE 0.72 (95% CI 0.69–0.74).ConclusionThe modified PRACTICE score can be a useful prognostic predictor in elderly patients with UTI.     

Vitamin D deficiency is Associated with Increased Risk of Delirium and Mortality among Critically Ill,Elderly Covid-19 Patients

Background and aimData on the associations of vitamin D levels with severe outcomes of coronavirus disease 2019 (COVID-19) among critically ill elderly patients are not conclusive and also no information is available about some outcomes such as delirium. Therefore, the current study was done to assess these associations in critically ill elderly COVID-19 patients.MethodsIn total, 310 critically ill COVID-19 patients, aged ≥ 65 years, were included in the current single center prospective study. All patients were hospitalized in the intensive care unit (ICU). We collected data on demographic characteristics, laboratory parameters, blood pressure, comorbidities, medications, and types of mechanical ventilation at baseline (the first day of ICU admission). Patients were categorized based on serum 25(OH)D3 levels at the baseline [normal levels (>30 ng/mL), insufficiency (20–30 ng/mL), deficiency (<20 ng/mL)]. Data on delirium incidence, mortality, invasive mechanical ventilation (IMV) requirement during treatment, length of ICU and hospital admission, and re-hospitalization were recorded until 45 days after the baseline.ResultsVitamin D deficiency and insufficiency were prevalent among 12 % and 37 % of study participants, respectively. In terms of baseline differences, patients with vitamin D deficiency were more likely to be older, have organ failure, take propofol, need IMV, and were less likely to need face mask compared to patients with normal levels of vitamin D. A significant positive association was found between vitamin D deficiency and risk of delirium. After controlling for potential confounders, patients with vitamin D deficiency had a 54 % higher risk of delirium compared to those with vitamin D sufficiency (HR: 1.54, 95 % CI: 1.02–2.33). Such a positive association was also seen for 45-day COVID-19 mortality (HR: 3.95, 95 % CI: 1.80–8.67). Also, each 10 ng/mL increase in vitamin D levels was associated with a 45 % and 26 % lower risk of 45-day mortality (HR: 0.55, 95 % CI: 0.40–0.74) and ICU mortality due to COVID-19 (HR: 0.74, 95 % CI: 0.60–0.92), respectively. In terms of other COVID-19 outcomes including IMV requirement during treatment, prolonged hospitalization, and re-hospitalization, we found no significant association in relation to serum 25(OH)D3 levels either in crude or fully adjusted models.ConclusionVitamin D deficiency was associated with an increased risk of delirium and mortality among critically ill elderly COVID-19 patients.