Risk factors and prognostic predictors of unexpected intensive care unit admission within 3 days after ED discharge

Objective

Our objective was to investigate the risk factors and prognostic predictors of unexpected intensive care unit (ICU) admission within 3 days after emergency department (ED) discharge.

Methods

From January 1, 2001, through December 31, 2005, patients admitted to the ICU unexpectedly within 3 days after being discharged from the ED were enrolled. Medical records of these patients were retrospectively reviewed. We categorized each patient's characteristics into dichotomous groups and used the χ² test to identify risk factors for unexpected ICU admission within 3 days after ED discharge. A multiple logistic regression was applied to examine possible independent predictors of poor prognoses.

Results

During the study period, 365 321 patients visited our ED; 241(0.07%) were unexpectedly admitted to the ICU within 3 days after being discharged from the ED. Mean patient age was 74.2 ± 16.4 years. The rate of ICU admissions caused by medical error was 0.019% ± 0.004% of all visits and 29.0% ± 5.7% of all unexpected ICU admissions. The overall mortality rate was 19.9% (48/241). Risk factors for unexpected ICU admission within 3 days after discharge from the ED were age of 65 years or older (odds ratio [OR], 5.4; 95% confidence interval [CI], 4.0-7.4), ambulance transport (OR, 5.1; 95% CI, 3.9-6.5), no accompanying family (OR, 3.5; 95% CI, 2.7-4.5), nonambulatory status (OR, 4.2; 95% CI, 2.9-5.0), not living at home (OR, 2.5; 95% CI, 1.9-3.3), Medicaid insurance (OR, 3.6; 95% CI, 2.8-4.7), and emergency stay of more than 24 hours (OR, 4.4; 95% CI, 3.4-5.7). The independent predictors of mortality were age of 65 years or older (OR, 2.4; 95% CI, 1.7-3.6), multiple comorbidities (OR, 4.0; 95% CI, 1.8-8.5), medical error leading to ICU admission (OR, 3.9; 95% CI, 1.8-8.3), and Acute Physiology and Chronic Health Evaluation II score of 20 or higher (OR, 2.9; 95% CI, 1.1-7.8).

Conclusions

In our study, the risk factors and prognostic predictors of unexpected ICU admission within 3 days after ED discharge were identified. Based on these risk and prognostic prediction factors, further strategies for decreasing the incidence of serious adverse events of ED-discharged patients can be implemented.     

Impact of antifungal treatment on <Emphasis Type="Italic">Candida</Emphasis>–<Emphasis Type="Italic">Pseudomonas</Emphasis> interaction: a preliminary retrospective case–control study

OBJECTIVE: A pathogenic interaction between Candida albicans and Pseudomonas aeruginosa has recently been demonstrated. In addition, experimental and clinical studies identified Candida spp. tracheobronchial colonization as a risk factor for P. aeruginosa pneumonia. The aim of this study was to determine the impact of antifungal treatment on ventilator-associated pneumonia (VAP) or tracheobronchial colonization due to P. aeruginosa. DESIGN AND SETTING: Retrospective observational case-control study conducted in a 30-bed ICU during a 1-year period. PATIENTS AND METHODS: One hundred and two patients intubated and ventilated for longer than 48 h with tracheobronchial colonization by Candida spp. Routine screening for Candida spp. and P. aeruginosa was performed at ICU admission and weekly. Antifungal treatment was based on medical staff decisions. Patients with P. aeruginosa VAP or tracheobronchial colonization were matched (1:2) with patients without P. aeruginosa VAP or tracheobronchial colonization. In case and control patients, risk factors for P. aeruginosa VAP or tracheobronchial colonization were determined using univariate and multivariate analyses. RESULTS: Thirty-six patients (35%) received antifungal treatment. Nineteen patients (18%) developed a P. aeruginosa VAP or tracheobronchial colonization, and all were successfully matched. Antifungal treatment [31% vs 60%; p=0.037, OR (95% CI)=0.67 (0.45-0.90)], and duration of antifungal treatment (7+/-11 vs 14+/-14 days; p=0.045, in case and control patients respectively) were significantly associated with reduced risk for P. aeruginosa VAP or tracheobronchial colonization. Antifungal treatment was the only variable independently associated with P. aeruginosa VAP or tracheobronchial colonization (OR=0.68, 95% CI=0.49-0.90, p=0.046). CONCLUSION: In patients with Candida spp. tracheobronchial colonization, antifungal treatment may be associated with reduced risk for P. aeruginosa VAP or tracheobronchial colonization.     

A comparison of outcomes between diabetic and nondiabetic CAPD patients in India

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) has been an established modality of renal replacement therapy in India for a decade, but there is a paucity of published data on the outcome of CAPD patients in India. We analyzed our data to determine the overall predictors of survival and compared patient survival between diabetic and nondiabetic end-stage renal disease patients on CAPD. METHODS: Of 373 patients, 197 were diabetic (165 males, 32 females) and 176 nondiabetic (104 males, 72 females). Patients were followed for 22 +/- 14 patient-months. Patients were prospectively followed until the study end point or death. RESULTS: Overall median survival was 48 patient-months. Median survival of diabetics (34.5 patient-months) was significantly inferior to nondiabetic patients (59 patient-months) p = 0.001. Overall patient survival at 1, 2, 3, 4, and 5 years was 90%, 72%, 60%, 49%, and 39%, respectively. Patient survival of diabetics versus nondiabetics at 1, 2, 3, 4, and 5 years was 85% versus 96%, 62% vs 82%, 48% vs 72%, 39% vs 62%, and 34% vs 42%, respectively. The relative risk of mortality in nondiabetics (34/176) was less than that in diabetic patients (71/197): odds ratio (OR) 0.43, 95% confidence interval (CI) 0.26 - 0.68; p = 0.001. On Cox regression analysis, diabetes (OR 1.95, 95% CI 1.23 - 3.07; p = 0.004), comorbidities (OR 0.39, 95% CI 0.25 - 0.61; p = 0.001), peritonitis (OR 1.79, 95% CI 1.19 - 2.68; p = 0.005), malnutrition (OR 0.52, 95% CI 0.29 - 0.94; p = 0.03), and residual glomerular filtration rate at initiation of CAPD (OR 0.87, 95% CI 0.81 - 0.93; p = 0.001) were significant predictors of overall mortality. Age (OR 0.68, 95% CI 0.45 - 1.03; p = 0.07), gender (OR 0.66, 95% CI 0.42 - 1.03; p = 0.06), and albumin level at initiation of CAPD (OR 0.92, 95% CI 0.64 - 1.33; p = 0.68) were not predictors of mortality. Age (56 +/- 10 vs 46 +/- 15 years, p = 0.001), comorbidities (51/197 vs 16/176, p = 0.001), peritonitis rate (0.68 vs 0.50 episodes/patient-year, p = 0.056), and severe malnutrition (27/197 vs 10/176, p = 0.002) were higher in diabetic than in nondiabetic patients. CONCLUSION: In India the majority of CAPD patients are diabetic. Patient survival was inferior in diabetic compared to nondiabetic patients on CAPD, but survival was statistically similar after adjustment for comorbidities. Diabetes, comorbidities, residual glomerular filtration rate, peritonitis, and severe malnutrition are predictors of mortality in CAPD patients.     

Critical illness polyneuropathy: risk factors and clinical consequences. A cohort study in septic patients

OBJECTIVE: To determine risk factors and clinical consequences of critical illness polyneuropathy (CIP) evaluated by the impact on duration of mechanical ventilation, length of stay and mortality. DESIGN: Inception cohort study. SETTING: Intensive care unit of a tertiary hospital. PATIENTS: Septic patients with multiple organ dysfunction syndrome requiring mechanical ventilation and without previous history of polyneuropathy. INTERVENTIONS: Patients underwent two scheduled electrophysiologic studies (EPS): on the 10th and 21st days after the onset of mechanical ventilation. RESULTS: Eighty-two patients were enrolled, although nine of them were not analyzed. Forty-six of the 73 patients presented CIP on the first EPS and 4 other subjects were diagnosed with CIP on the second evaluation. The APACHE II scores of patients with and without CIP were similar on admission and on the day of the first EPS. However, days of mechanical ventilation [32.3 (21.1) versus 18.5 (5.8); p=0.002], length of ICU and hospital stay in patients discharged alive from the ICU as well as in-hospital mortality were greater in patients with CIP (42/50, 84% versus 13/23, 56.5%; p=0.01). After multivariate analysis, independent risk factors were hyperosmolality [odds ratio (OR) 4.8; 95% confidence intervals (95% CI) 1.05-24.38; p=0.046], parenteral nutrition (OR 5.11; 95% CI 1.14-22.88; p=0.02), use of neuromuscular blocking agents (OR 16.32; 95% CI 1.34-199; p=0.0008) and neurologic failure (GCS below 10) (OR 24.02; 95% CI 3.68-156.7; p<0.001), while patients with renal replacement therapy had a lower risk for CIP development (OR 0.02; 95% CI 0.05-0.15; p<0.001). By multivariate analysis, CIP (OR 7.11; 95% CI 1.54-32.75; p<0.007), age over 60 years (OR 9.07; 95% CI 2.02-40.68; p<0.002) and the worst renal SOFA (OR 2.18; 95% CI 1.27-3.74; p<0.002) were independent predictors of in-hospital mortality. CONCLUSIONS: CIP is associated with increased duration of mechanical ventilation and in-hospital mortality. Hyperosmolality, parenteral nutrition, non-depolarizing neuromuscular blockers and neurologic failure can favor CIP development.     

Impact of inappropriate antibiotic therapy on mortality in patients with ventilator-associated pneumonia and blood stream infection: a meta-analysis

OBJECTIVES: Studies have found that initial treatment of ventilator-associated pneumonia (VAP) and blood stream infections (BSI) with inappropriate antimicrobial therapy is associated with higher rates of mortality, but additional studies have failed to confirm this. METHODS: Databases were searched to identify studies that met the following criteria: observational trials, patients with VAP or BSI receiving appropriate and inappropriate antimicrobial therapy, and mortality data. We conducted random-effects model meta-analyses, both with and without adjustment. RESULTS: Meta-analyses of VAP studies using unadjusted and adjusted data indicated that inappropriate therapy significantly increased patients' odds of mortality (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.51-3.63; P = .0001, I 2 = 28.5% and OR, 3.03; 95% CI, 1.12-8.19; P = .0292, I 2 = 89.2%, respectively). Meta-analyses of BSI studies using unadjusted and adjusted data showed that inappropriate therapy significantly increased patients' odds of mortality (OR, 2.33; 95% CI, 1.96-2.76; P < .0001, I 2 = 48.7% and OR, 2.28; 95% CI, 1.43-3.65; P = .0006, I 2 = 88.2%, respectively). CONCLUSIONS: There appears to be an association between initial inappropriate antimicrobial therapy and increased mortality in patients with VAP and BSI.     

Incidence and risk factors for ventilator-associated pneumonia in 4 multidisciplinary intensive care units in Athens,Greece

INTRODUCTION: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection among intensive care unit (ICU) patients. OBJECTIVE: Prospectively identify the factors associated with development of VAP and examine the incidence of VAP. SUBJECTS: Over a 6-month period we had 175 patients who required mechanical ventilation for longer than 24 hours. RESULTS: VAP occurred in 56 patients (32%). Stepwise logistic regression analysis identified 5 factors independently associated with VAP (p < 0.05): bronchoscopy (adjusted odds ratio [AOR] = 2.95; 95% confidence interval [CI], 1.1-8.3; p = 0.036); tube thoracostomy (AOR = 2.78; 95% CI, 1.1-6.6; p = 0.023); tracheostomy (AOR = 3.56; 95% CI, 1.7-8.4; p = 0.002); Acute Physiology and Chronic Health Evaluation (APACHE II) score >/= 18 (AOR = 2.33; 95% CI, 1.1-5.1; p = 0.033); and enteral feeding (AOR = 2.89; 95% CI, 1.3-7.7; p = 0.026). The duration of mechanical ventilation was longer among patients who developed VAP (p < 0.001). VAP was not associated with the cause of ICU admission. CONCLUSIONS: VAP is a common infection and certain interventions might affect the incidence of VAP. ICU clinicians should be aware of the risk factors for VAP, which could prove useful in identifying patients at high risk for VAP and modifying patient care to minimize the risk of VAP, such as avoiding unnecessary bronchoscopy or modulating enteral feeding.     

Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis

OBJECTIVES: Our primary goal was to evaluate the impact on in-hospital mortality rate of adequate empirical antibiotic therapy, after controlling for confounding variables, in a cohort of patients admitted to the intensive care unit (ICU) with sepsis. The impact of adequate empirical antibiotic therapy on early (<3 days), 28-day, and 60-day mortality rates also was assessed. We determined the risk factors for inadequate empirical antibiotic therapy.DESIGN Prospective cohort study. SETTING: ICU of a tertiary hospital. PATIENTS: All the patients meeting criteria for sepsis at admission to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred and six patients were included. Microbiological documentation of sepsis was obtained in 67% of the patients. At ICU admission, sepsis was present in 105 patients (25.9%), severe sepsis in 116 (28.6%), and septic shock in 185 (45.6%). By multivariate analysis, predictors of in-hospital mortality were Sepsis-related Organ Failure Assessment (SOFA) score at ICU admission (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.19-1.40), the increase in SOFA score over the first 3 days in the ICU (OR, 1.40; 95% CI, 1.19-1.65), respiratory failure within the first 24 hrs in the ICU (OR, 3.12; 95% CI, 1.54-6.33), and inadequate empirical antimicrobial therapy in patients with "nonsurgical sepsis" (OR, 8.14; 95% CI, 1.98-33.5), whereas adequate empirical antimicrobial therapy in "surgical sepsis" (OR, 0.37; 95% CI, 0.18-0.77) and urologic sepsis (OR, 0.14; 95% CI, 0.05-0.41) was a protective factor. Regarding early mortality (<3 days), factors associated with fatality were immunosuppression (OR, 4.57; 95% CI, 1.69-13.87), chronic cardiac failure (OR, 9.83; 95% CI, 1.98-48.69) renal failure within the first 24 hrs in the unit (OR, 8.63; 95% CI, 3.31-22.46), and respiratory failure within the first 24 hrs in the ICU (OR, 12.35; 95% CI, 4.50-33.85). Fungal infection (OR, 47.32; 95% CI, 5.56-200.97) and previous antibiotic therapy within the last month (OR, 2.23; 95% CI, 1.1-5.45) were independent variables related to administration of inadequate antibiotic therapy. CONCLUSIONS: In patients admitted to the ICU for sepsis, the adequacy of initial empirical antimicrobial treatment is crucial in terms of outcome, although early mortality rate was unaffected by the appropriateness of empirical antibiotic therapy.     

Prognostic factors in critically ill cancer patients admitted to the intensive care unit

Objective

The objective of this study is to identify factors predicting intensive care unit (ICU) mortality in cancer patients admitted to a medical ICU.

Patients and methods

We conducted a retrospective study in 162 consecutive cancer patients admitted to the medical ICU of a 1000-bed university hospital between January 2009 and June 2012. Medical history, physical and laboratory findings on admission, and therapeutic interventions during ICU stay were recorded. The study end point was ICU mortality. Logistic regression analysis was performed to identify independent risk factors for ICU mortality.

Results

The study cohort consisted of 104 (64.2%) patients with solid tumors and 58 patients (35.8%) with hematological malignancies. The major causes of ICU admission were sepsis/septic shock (66.7%) and respiratory failure (63.6%), respectively. Overall ICU mortality rate was 55 % (n = 89). The ICU mortality rates were similar in patients with hematological malignancies and solid tumors (57% vs 53.8%; P = .744). Four variables were independent predictors for ICU mortality in cancer patients: the remission status of the underlying cancer on ICU admission (odds ratio [OR], 0.113; 95% confidence interval [CI], 0.027-0.48; P = .003), Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.032-1.215; P = .007), sepsis/septic shock during ICU stay (OR, 8.94; 95% CI, 2.28-35; P = .002), and vasopressor requirement (OR 16.84; 95% CI, 3.98-71.24; P = .0001). Although Acute Physiology and Chronic Health Evaluation II score (OR, 1.30; 95% CI, 1.054-1.61; P = .014), admission through emergency service (OR, 0.005; 95% CI, 0.00-0.69; P = .035), and vasopressor requirement during ICU stay (OR, 140.64; 95% CI, 3.59-5505.5; P = .008) were independent predictors for ICU mortality in patients with hematological malignancies, Sequential Organ Failure Assessment score (OR, 1.83; 95% CI, 1.29-2.6; P = .001), lactate dehydrogenase level on admission (OR, 1.002; 95% CI, 1-1.005; P = .028), sepsis/septic shock during ICU stay (OR, 138.4; 95% CI, 12.54-1528.4; P = .0001), and complete or partial remission of the underlying cancer (OR, 0.026; 95% CI, 0.002-0.3; P = .004) were the independent risk factors in patients with solid tumors.

Conclusion

Intensive care unit mortality rate was 55% in our cancer patients, which suggests that patients with cancer can benefit from ICU admission. We also found that ICU mortality rates of patients with hematological malignancies and solid tumors were similar.     

Ventilator-associated pneumonia caused by multidrug-resistant organisms or Pseudomonas aeruginosa: prevalence, incidence, risk factors, and outcomes

PURPOSE: The aim of this study was to clarify the prevalence and incidence of, risk factors for, and outcomes from suspected ventilator-associated pneumonia (VAP) associated with the isolation of either Pseudomonas or multidrug-resistant (MDR) bacteria ("high risk" pathogens) from respiratory secretions. MATERIALS AND METHODS: Data were collected as part of a large, multicentered trial of diagnostic and therapeutic strategies for patients (n = 739) with suspected VAP. RESULTS: At enrollment, 6.4% of patients had Pseudomonas species, and 5.1% of patients had at least 1 MDR organism isolated from respiratory secretions. Over the study period, the incidence of Pseudomonas and MDR organisms was 13.4% and 9.2%, respectively. Independent risk factors for the presence of these pathogens at enrollment were duration of hospital stay >or=48 hours before intensive care unit (ICU) admission (odds ratio, 2.37 [95% CI, 1.40-4.02]; P = .001] and prolonged duration of ICU stay before enrollment (odds ratio, 1.50 [95% CI, 1.17-1.93]; P = .002] per week. Fewer patients whose specimens grew either Pseudomonas or MDR organisms received appropriate empirical antibiotic therapy compared to those without these pathogens (68.5% vs 93.9%, P < .001). The isolation of high risk pathogens from respiratory secretions was associated with higher 28-day (relative risk, 1.59 [95% CI, 1.07-2.37]; P = .04] and hospital mortality (relative risk, 1.48 [95% CI, 1.05-2.07]; P = .05), and longer median duration of mechanical ventilation (12.6 vs 8.7 days, P = .05), ICU length of stay (16.2 vs 12.0 days, P = .05), and hospital length of stay (55.0 vs 41.8 days, P = .05). CONCLUSIONS: In this patient population, the incidence of high-risk organisms newly acquired during an ICU stay is low. However, the presence of high risk pathogens is associated with worse clinical outcomes.     

Impact of ureido/carboxypenicillin resistance on the prognosis of ventilator-associated pneumonia due to Pseudomonas aeruginosa

Introduction

Although Pseudomonas aeruginosa is a leading pathogen responsible for ventilator-associated pneumonia (VAP), the excess in mortality associated with multi-resistance in patients with P. aeruginosa VAP (PA-VAP), taking into account confounders such as treatment adequacy and prior length of stay in the ICU, has not yet been adequately estimated.

Methods

A total of 223 episodes of PA-VAP recorded into the Outcomerea database were evaluated. Patients with ureido/carboxy-resistant P. aeruginosa (PRPA) were compared with those with ureido/carboxy-sensitive P. aeruginosa (PSPA) after matching on duration of ICU stay at VAP onset and adjustment for confounders.

Results

Factors associated with onset of PRPA-VAP were as follows: admission to the ICU with septic shock, broad-spectrum antimicrobials at admission, prior use of ureido/carboxypenicillin, and colonization with PRPA before infection. Adequate antimicrobial therapy was more often delayed in the PRPA group. The crude ICU mortality rate and the hospital mortality rate were not different between the PRPA and the PSPA groups. In multivariate analysis, after controlling for time in the ICU before VAP diagnosis, neither ICU death (odds ratio (OR) = 0.73; 95% confidence interval (CI): 0.32 to 1.69; P = 0.46) nor hospital death (OR = 0.87; 95% CI: 0.38 to 1.99; P = 0.74) were increased in the presence of PRPA infection. This result remained unchanged in the subgroup of 87 patients who received adequate antimicrobial treatment on the day of VAP diagnosis.

Conclusions

After adjustment, and despite the more frequent delay in the initiation of an adequate antimicrobial therapy in these patients, resistance to ureido/carboxypenicillin was not associated with ICU or hospital death in patients with PA-VAP.     

Impact of piperacillin resistance on the outcome of Pseudomonas ventilator-associated pneumonia

Background The impact of antibiotic resistance on the outcome of infections due to Gram-negative bacilli, especially Pseudomonas, remains highly controversial.Study objective, design, and patients We evaluated the impact of piperacillin resistance on the outcomes of Pseudomonas aeruginosa ventilator-associated pneumonia (VAP) for patients who had received appropriate empiric antibiotics before enrollment in the PNEUMA trial, a multicenter randomized study comparing 8 vs 15 days of antibiotics.Results Despite similar characteristics at intensive care unit (ICU) admission, patients infected with piperacillin-resistant Pseudomonas strains were more acutely ill at VAP onset and had a higher 28-day mortality rate (37 vs 19%; P = 0.04) than those with piperacillin-susceptible Pseudomonas VAP. Factors associated with 28-day mortality retained by multivariable analysis were: age (OR: 1.07; 95% CI: 1.03–1.12); female gender (OR: 4.00; 95% CI: 1.41–11.11); severe underlying comorbidities (OR: 2.73; 95% CI: 1.02–7.33); and SOFA score (OR: 1.17; 95% CI: 1.03–1.32), but piperacillin resistance did not reach statistical significance (OR: 2.00; 95% CI: 0.72–5.61). The VAP recurrence rates, either superinfection or relapse, and durations of mechanical ventilation and ICU stay did not differ as a function of Pseudomonas-resistance status.Conclusions For patients with Pseudomonas VAP benefiting from appropriate empiric antibiotics, piperacillin resistance was associated with increased disease severity at VAP onset and higher 28-day crude mortality; however, after controlling for confounders, piperacillin-resistance was no longer significantly associated with 28-day mortality. The VAP recurrence rates and durations of ICU stay and mechanical ventilation did not differ for susceptible and resistant strains.     

Impact of intensive care unit admission during morning bedside rounds and mortality: a multi-center retrospective cohort study

ABSTRACT: INTRODUCTION: Recent data have suggested that patient admission during intensive care unit (ICU) morning bedside rounds is associated with less favorable outcome. We undertook the present study to explore the association between morning round-time ICU admissions and hospital mortality in a large Canadian health region. METHODS: A multi-center retrospective cohort study was performed at five hospitals in Edmonton, Canada, between July 2002 and December 2009. Round-time ICU admission was defined as occurring between 8 and 11:59 a.m. Multivariable logistic regression analysis was used to explore the association between round-time admission and outcome. RESULTS: Of 18,857 unique ICU admissions, 2,055 (10.9%) occurred during round time. Round-time admissions were more frequent in community hospitals compared with tertiary hospitals (12.0% vs. 10.5%; odds ratio [OR] 1.16; 95% CI, 1.05-1.29, P < 0.004) and from the ward compared with the emergency department (ED) or operating theater (17.5% vs. 9.2%; OR 2.1; 95% CI, 1.9-2.3, P < 0.0001). Round-time admissions were more often medical than surgical (12.6% vs. 6.6%; OR 2.06; 95% CI, 1.83-2.31, P < 0.0001), had more comorbid illness (11.9% vs. 10.5%; OR 1.15; 95% CI, 1.04-1.27, P < 0.008) and higher APACHE II score (22.2 vs. 21.3, P < 0.001), and were more likely to have a primary diagnosis of respiratory failure (37.0% vs. 31.3%, P < 0.001) or sepsis (11.1% vs. 9.0%, P = 0.002). Crude ICU mortality (15.3% vs. 11.6%; OR 1.38; 95% CI, 1.21-1.57, P < 0.0001) and hospital mortality (23.9% vs. 20.6%; OR 1.21; 95% CI, 1.09-1.35, P < 0.001) were higher for round-time compared with non-round-time admissions. In multi-variable analysis, round-time admission was associated with increased ICU mortality (OR 1.19, 95% CI, 1.03-1.38, P = 0.017) but was not significantly associated with hospital mortality (OR 1.02; 95% CI, 0.90-1.16, P = 0.700). In the subgroup admitted from the ED, round-time admission showed significantly higher ICU mortality (OR 1.54; 95% CI, 1.21-1.95; P < 0.001) and a trend for higher hospital mortality (OR 1.22; 95% CI, 0.99-1.51, P = 0.057). CONCLUSIONS: Approximately 1 in 10 patients is admitted during morning rounds. These patients are more commonly admitted from the ward and are burdened by comorbidities, are non-operative, and have higher illness severity. These patients admitted during morning rounds have higher observed ICU mortality but no difference in hospital mortality.     

Identifying Infected Emergency Department Patients Admitted to the Hospital Ward at Risk of Clinical Deterioration and Intensive Care Unit Transfer

Objectives: An important challenge faced by emergency physicians (EPs) is determining which patients should be admitted to an intensive care unit (ICU) and which can be safely admitted to a regular ward. Understanding risk factors leading to undertriage would be useful, but these factors are not well characterized. Methods: The authors performed a secondary analysis of two prospective, observational studies of patients admitted to the hospital with clinically suspected infection from an urban university emergency department (ED). Inclusion criteria were as follows: adult ED patient (age 18 years or older), ward admission, and suspected infection. The primary outcome was transfer to an ICU within 48 hours of admission. Using multiple logistic regression, independent predictors of early ICU transfer were identified, and the area under the curve for the model was calculated. Results: Of 5,365 subjects, 93 (1.7%) were transferred to an ICU within 48 hours. Independent predictors of ICU transfer included respiratory compromise (odds ratio [OR] = 2.5, 95% confidence interval [CI] = 1.4 to 4.3), congestive heart failure (CHF; OR = 2.2, 95% CI = 1.4 to 3.6), peripheral vascular disease (OR = 2.0, 95% CI = 1.1 to 3.7), systolic blood pressure (sBP) < 100 mm Hg (OR = 1.9, 95% CI = 1.2 to 2.9), heart rate > 90 beats/min (OR = 1.8, 95% CI = 1.1 to 2.8), and creatinine > 2.0 (OR = 1.8, 95% CI = 1.1 to 2.8). Cellulitis was associated with a lower likelihood of ICU transfer (OR = 0.33, 95% CI = 0.15 to 0.72). The area under the curve for the model was 0.73, showing moderate discriminatory ability. Conclusions: In this preliminary study, independent predictors of ICU transfer within 48 hours of admission were identified. While somewhat intuitive, physicians should consider these factors when determining patient disposition. ACADEMIC EMERGENCY MEDICINE 2010; 17:1080–1085 © 2010 by the Society for Academic Emergency Medicine     

Predictors of carbapenem-resistant Klebsiella pneumoniae acquisition among hospitalized adults and effect of acquisition on mortality

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an emerging nosocomial pathogen. Little is known about its risk factors or mortality. We performed a case-case-control study to assess the risks for CRKP isolation and a retrospective cohort study to assess mortality in three groups of hospitalized adults: (i) patients from whom CRKP was isolated, (ii) patients from whom carbapenem-susceptible Klebsiella spp. (CSKS) were isolated, and (iii) controls from whom no Klebsiella spp. were isolated. After adjustment for length of stay (LOS), the demographics, comorbidities, and exposures of each case group were compared with those of the controls. Significant covariates were incorporated into LOS-adjusted multivariable models. In the mortality study, we evaluated the effect of CRKP on in-hospital death. There were 48 patients with CRKP isolation (21 died [44%]), 56 patients with CSKS isolation (7 died [12.5%]), and 59 controls (1 died [2%]). Independent risk factors for CRKP isolation were poor functional status (odds ratio [OR], 15.4; 95% confidence interval [CI], 4.0 to 58.6; P < 0.001); intensive care unit (ICU) stay (OR, 17.4; 95% CI, 1.5 to 201.9; P = 0.02); and receipt of antibiotics (OR, 4.4; 95% CI, 1.0 to 19.2; P = 0.05), particularly fluoroquinolones (OR, 7.2; 95% CI, 1.1 to 49.4; P = 0.04). CRKP was independently associated with death when patients with CRKP were compared with patients with CSKS (OR, 5.4; 95% CI, 1.7 to 17.1; P = 0.005) and with controls (OR, 6.7; 95% CI, 2.4 to 18.8; P < 0.001). After adjustment for the severity of illness, CRKP isolation remained predictive of death, albeit with a lower OR (for the CRKP group versus the CSKS group, OR, 3.9; 95% CI, 1.1 to 13.6; and P = 0.03; for the CRKP group versus the controls, OR, 5.0; 95% CI, 1.7 to 14.8; and P = 0.004). CRKP affects patients with poor functional status, an ICU stay, and antibiotic exposure and is an independent predictor of death.     

Prospective Multicenter Bronchiolitis Study: Predicting Intensive Care Unit Admissions

Objectives: The authors sought to identify predictors of intensive care unit (ICU) admission among children hospitalized with bronchiolitis for ≥24 hours. Methods: The authors conducted a prospective cohort study during two consecutive bronchiolitis seasons, 2004 through 2006, in 30 U.S. emergency departments (EDs). All included patients were aged <2 years and had a final diagnosis of bronchiolitis. Regular floor versus ICU admissions were compared. Results: Of 1,456 enrolled patients, 533 (37%) were admitted to the regular floor and 50 (3%) to the ICU. Comparing floor and ICU admissions, multivariate ED predictors of ICU admission were age <2 months (26% vs. 53%; odds ratio [OR] = 4.1; 95% confidence interval [CI] = 2.1 to 8.3), an ED visit the past week (25% vs. 40%; OR = 2.2; 95% CI = 1.1 to 4.4), moderate/severe retractions (31% vs. 48%; OR = 2.6; 95% CI = 1.3 to 5.2), and inadequate oral intake (31% vs. 53%; OR = 3.3; 95% CI = 1.6 to 7.1). Unlike previous studies, no association with male gender, socioeconomic factors, insurance status, breast‐feeding, or parental asthma was found with ICU admission. Conclusions: In this prospective multicenter ED‐based study of children admitted for bronchiolitis, four independent predictors of ICU admission were identified. The authors did not confirm many putative risk factors, but cannot rule out modest associations.     

益生菌对脓毒症机械通气患者呼吸机相关性肺炎发病的影响

目的:探讨益生菌治疗在降低脓毒症机械通气患者呼吸机相关性肺炎（ventilator-associated pneumonia,VAP）中的应用效果。方法:选取入住本院ICU的脓毒症机械通气的患者共94例,随机（随机数字法）分为益生菌组（ n=46）和对照组（ n=48）,两组患者均于入院后24~...     

ICU机械通气患者呼吸机相关性肺炎危险因素与护理对策

目的探讨ICU机械通气患者呼吸机相关性肺炎(VAP)发生的危险因素及护理对策,为临床降低VAP发生率提供理论支持。方法选取2018年1月至2019年6月在我院ICU机械通气患者175例为研究对象,并发VAP 60例。采用多因素logistic回归分析法分析VAP发生危险因素。结果多因素logistic回归分析结果显示,年龄(OR=1.624)、APACHEⅡ评分(OR=1.915)、侵袭性操作(OR=1.942)、口腔清洁状况(OR=2.178)、机械通气时间(OR=2.652)、意识障碍(OR=2.154)为影响ICU机械通气VAP发生的独立危险因素(P<0.05)。结论ICU机械通气患者VAP发生的危险因素多且复杂,应采取针对性干预措施,尽量缩短机械通气、住院时间,加强防护,降低VAP发生风险,促进患者康复。     

Risk factors for carbapenem-resistant Gram-negative bacteremia in intensive care unit patients

Purpose

Carbapenem-resistant (CR) Gram-negative pathogens have increased substantially. This study was performed to identify the risk factors for development of CR Gram-negative bacteremia (GNB) in intensive care unit (ICU) patients.

Methods

Prospective study; risk factors for development of CR-GNB were investigated using two groups of case patients: the first group consisted of patients who acquired carbapenem susceptible (CS) GNB and the second group included patients with CR-GNB. Both case groups were compared to a shared control group defined as patients without bacteremia, hospitalized in the ICU during the same period.

Results

Eighty-five patients with CR- and 84 patients with CS-GNB were compared to 630 control patients, without bacteremia. Presence of VAP (OR 7.59, 95 % CI 4.54–12.69, p < 0.001) and additional intravascular devices (OR 3.69, 95 % CI 2.20–6.20, p < 0.001) were independently associated with CR-GNB. Presence of VAP (OR 2.93, 95 % CI 1.74–4.93, p < 0.001), presence of additional intravascular devices (OR 2.10, 95 % CI 1.23–3.60, p = 0.007) and SOFA score on ICU admission (OR 1.11, 95 % CI 1.03–1.20, p = 0.006) were independently associated with CS-GNB. The duration of exposure to carbapenems (OR 1.079, 95 % CI 1.022–1.139, p = 0.006) and colistin (OR 1.113, 95 % CI 1.046–1.184, p = 0.001) were independent risk factors for acquisition of CR-GNB. When the source of bacteremia was other than VAP, previous administration of carbapenems was the only factor related with the development of CR-GNB (OR 1.086, 95 % CI 1.003–1.177, p = 0.042).

Conclusions

Among ICU patients, VAP development and the presence of additional intravascular devices were the major risk factors for CR-GNB. In the absence of VAP, prior use of carbapenems was the only factor independently related to carbapenem resistance.     

ICU患者发生获得性衰弱的危险因素分析

目的分析ICU患者发生获得性衰弱的危险因素。 方法选择2015年6月至2018年9月南充市中心医院ICU收治的280例患者作为研究对象,其中63例患者发生ICU获得性衰弱,217例患者未发生ICU获得性衰弱。根据临床工作经验,将与ICU获得性衰弱有直接或间接尚待求证的因素如性别、年龄、体质量指数（BMI）、入ICU时简化急性生理学评分（SAPS）Ⅱ、急性病生理学和长期健康评价（APACHE）Ⅱ评分、意识障碍、高血压、高血糖、来源科室、弥散性血管内凝血（DIC）、脓毒症、脓毒性休克、多器官功能障碍综合征（MODS）、长期卧床制动、低蛋白血症、机械通气时间、应用糖皮质激素、应用神经肌肉阻滞剂、应用去甲肾上腺素、实施早期康复干预等因素纳入Logistic回归分析,筛选出ICU获得性衰弱的影响因素。 结果单因素Logistic回归分析结果显示,女性[比值比（OR）= 1.514,95%置信区间（CI）（1.074,1.328）,P = 0.042]、年龄≥ 60岁[OR = 1.613,95% CI（1.142,2.002）,P = 0.042]、SAPSⅡ评分≥ 25分[OR = 1.982,95% CI（1.003,2.925）,P = 0.013]、APACHEⅡ评分≥ 8分[OR = 1.770,95%CI（1.192,2.742）,P = 0.014]、高血糖[OR = 1.853,95%CI（1.035,2.214）,P = 0.015]、脓毒症[OR = 2.309,95%CI（1.013,3.063）,P = 0.021]、脓毒性休克[OR = 2.106,95%CI（1.995,4.947）,P = 0.025]、MODS [OR = 3.721,95%CI（1.001,4.980）,P = 0.007]、长期卧床制动[OR = 4.641,95%CI（1.932,5.253）,P < 0.001]、机械通气时间≥ 72 h [OR = 3.367,95%CI（1.635,4.254）,P = 0.005]、应用糖皮质激素[OR = 1.709,95%CI（1.424,2.757）,P = 0.021]、应用神经肌肉阻滞剂[OR = 2.042,95%CI（1.331,4.953）,P = 0.011]以及实施早期康复干预[OR = 0.586,95%CI（0.953,1.472）,P = 0.037]与ICU获得性衰弱相关。将其纳入多因素Logistic回归分析后发现,年龄≥ 60岁[OR =1.576,95%CI（1.095,1.753）,P = 0.038]、SAPSⅡ评分≥ 25分[OR = 1.988,95%CI（1.115,1.803）,P = 0.013]、APACHEⅡ评分≥ 8分[OR = 1.768,95%CI（1.189,2.364）,P = 0.014]、高血糖[OR = 1.680,95%CI（1.033,1.689）,P = 0.015]、脓毒症[OR = 1.842,95%CI（1.011,1.976）,P = 0.010]、长期卧床制动[OR = 4.745,95%CI（1.931,3.470）,P < 0.001]、机械通气时间≥ 72 h[OR = 3.353,95%CI（1.722,4.314）,P = 0.003]、应用神经肌肉阻滞剂[OR = 1.931,95%CI（1.247,2.573）,P = 0.005]是ICU患者发生获得性衰弱的独立危险因素,而实施早期康复干预[OR = 0.598,95%CI（0.978,1.674）,P = 0.037]是其保护因素。 结论ICU获得性衰弱的危险因素复杂,应加强高危患者的早期干预,积极控制好血糖,减少制动时间和机械通气时间,预防ICU获得性衰弱的发生。     

Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study

CONTEXT: In patients with hypoxemic acute respiratory failure (ARF), randomized studies have shown noninvasive positive pressure ventilation (NPPV) to be associated with lower rates of endotracheal intubation. In these patients, predictors of NPPV failure are not well characterized. OBJECTIVE: To investigate variables predictive of NPPV failure in patients with hypoxemic ARF. DESIGN: Prospective, multicenter cohort study. SETTING: Eight Intensive Care Units (ICU) in Europe and USA. PATIENTS: Of 5,847 patients admitted between October 1996 and December 1998, 2,770 met criteria for hypoxemic ARF. Of these, 2,416 were already intubated and 354 were eligible for the study. RESULTS: NPPV failed in 30% (108/354) of patients. The highest intubation rate was observed in patients with ARDS (51%) or community-acquired pneumonia (50%). The lowest intubation rate was observed in patients with cardiogenic pulmonary edema (10%) and pulmonary contusion (18%). Multivariate analysis identified age > 40 years (OR 1.72, 95% CI 0.92-3.23), a simplified acute physiologic score (SAPS II) > or = 35 (OR 1.81, 95% CI 1.07-3.06), the presence of ARDS or community-acquired pneumonia (OR 3.75, 95% CI 2.25-6.24), and a PaO2:FiO2 < or = 146 after 1 h of NPPV (OR 2.51, 95% CI 1.45-4.35) as factors independently associated with failure of NPPV. Patients requiring intubation had a longer duration of ICU stay ( P < 0.001), higher rates of ventilator-associated pneumonia and septic complications ( P < 0.001), and a higher ICU mortality ( P < 0.001). CONCLUSIONS: In hypoxemic ARF, NPPV can be successful in selected populations. When patients have a higher severity score, an older age, ARDS or pneumonia, or fail to improve after 1 h of treatment, the risk of failure is higher.