Outcome of patients with systemic rheumatic diseases admitted to intensive care units: a retrospective study of 39 cases

PURPOSE: Patients with systemic rheumatic diseases are rarely admitted in intensive care units and very few studies focusing on the prognosis of those patients have been published. METHODS: Retrospective study over seven years in two intensive care units. RESULTS: Among 33 patients with systemic disease diagnosed 90 +/- 133 months before admission in the intensive care unit, who were aged 50 +/- 21 years and represented a total of 39 stays in the intensive care unit, the main cause of admission was acute respiratory failure (33%). Mean simplified acute physiology score (SAPS II) was 47 +/- 22. Two-thirds of the patients were under mechanical ventilation. Infection was diagnosed in 33% of the cases and exacerbation of the systemic rheumatic disease in 26%. Nosocomial infection was found in 19 patients (49%). Ten patients died during their stay in the intensive care unit, six from infection, three from an exacerbation of the systemic rheumatic disease, one from an unidentified cause. CONCLUSION: Even if severity scores of patients suffering from systemic diseases are higher at admission in intensive care units than those of other patients, there is no relevant reason to refuse critical care to these patients.     

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

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

Discharge decision-making in a medical intensive care unit. Identifying patients at high risk of unexpected death or unit readmission

In an attempt to identify clinical variables associated with unexpected death or unit readmission following discharge from a medical intensive care unit (MICU), 300 consecutive patients admitted to a MICU were prospectively identified and followed through their hospital stay. Of the 229 patients at risk, 37 (16 percent) experienced one or more unexpected unit readmissions (n = 30) or death (n = 7). In comparison to the patients without such complications (n = 192), these 37 patients differed with respect to age, diagnosis, and severity of illness on admission. In addition, these patients were sicker on initial unit discharge as manifested by higher heart and respiratory rates and lower hematocrit values. On multivariate analysis, age, acute physiology score on admission, and a diagnosis of upper gastrointestinal bleeding were independent predictors of unexpected outcome. It is concluded that patients at high risk for unit readmission or unexpected death are distinguished from other MICU survivors on several clinical parameters. Whether such information can be useful in individual discharge decisions is uncertain and requires further investigation.     

Outcome of patients having dermatomyositis admitted to the intensive care unit

Patients having systemic rheumatic diseases constitute a small percentage of admissions to the medical intensive care units (ICUs). Dermatomyositis (DM) is one of the rheumatic diseases that have secondary complications that may lead to a critical illness requiring hospitalization in the ICU. Herein, we present the features, clinical course, and outcome of critically ill patients having DM who were admitted to the ICU. The medical records of six DM patients admitted to the ICU in a large tertiary hospital in a 12-year period were reviewed. The mean age of patients at time of admission to the ICU was 38 (range 16–37). Mean disease duration from diagnosis to admission to the ICU was 1.6 years (range 1 month–8 years), while the main reason for admission to the ICU was acute respiratory failure. Two of six patients died during the hospitalization. The main causes of death were respiratory complications and sepsis. The outcome of DM patients admitted to the ICU was generally not different from the outcome of other patients hospitalized in the ICU. The main reason for hospitalization was acute respiratory failure. As there are many reasons for respiratory failure in DM, an early diagnosis and aggressive appropriate treatment may help to further reduce the mortality in these patients.     

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

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

Low triiodothyronine syndrome: a prognostic marker for outcome in sepsis?

There is ongoing controversy as to whether hormonal changes of the euthyroid sick syndrome are predictors of poor outcome in sepsis and critical illness. In this prospective study, the prognostic accuracy of thyroid hormone levels in 103 critically ill adult patients on admission and during follow up in a medical intensive care unit (ICU) was assessed and was compared to clinical risk scores, namely, the acute physiology and chronic health evaluation and the simplified acute physiology score. Median T3 levels on admission to the ICU were lower in the 53 septic cases [0.9?nmol/l (IQR 0.6-1.1)] as compared with the 50 patients with a systemic inflammatory response syndrome [1.2?nmol/l (IQR 0.8-1.4), P?相似文献   

Prognosis of patients with acute myeloid leukaemia admitted to intensive care

This retrospective study assessed the prognostic factors associated with early and long-term outcome in consecutive patients with acute myeloid leukaemia (AML) admitted to the intensive care unit (ICU) over a 9-year period. A total of 83 patients were studied (age 48 +/- 16 years), among whom 60% were neutropenic on admission. For 68%, admission occurred within the first month following diagnosis of AML. The main reason for ICU admission was an acute respiratory disease in 82% of cases. Mechanical ventilation (MV) was required in 57% of patients. In-ICU mortality was 34%. Among patients discharged alive from ICU, 49% died within a year after discharge. Factors significantly associated with in-ICU death in multivariate analysis were simplified acute physiology score II and need for invasive MV (IMV). Age, performance status, AML3 subtype and complete remission were significantly associated with 1-year survival. Patients with acute respiratory failure initially supported with non-invasive MV had significantly better ICU outcome than patients initially supported with IMV. In conclusion, ICU admission is justified for selected patients with AML. The ICU mortality rate is highly predictable by the acute illness severity score. A 1-year survival is predicted by haematological prognostic factors.     

Is there a role for inhaled nitric oxide as a rescue therapy in respiratory failure associated with hematologic malignancies?

Inhaled nitric oxide has been demonstrated to improve oxygenation in critically ill patients requiring mechanical ventilation. We therefore performed a retrospective review to determine the outcome of patients with hematological malignancies and acute respiratory failure who received inhaled nitric oxide (INO) in a multidisciplinary intensive care unit of a single tertiary referral medical center.Thirteen patients with hematological malignancies who required endotracheal intubation and mechanical ventilation and received INO for acute respiratory failure between January 1998 and December 2002 were identified. Mean +/- standard deviation (SD) age was 47.6 (+/-13.2) years. The mean +/- SD Acute Physiology and Chronic Health Evaluation (APACHE) III score on the day of ICU admission was 94.1 +/- 33.7 with a mean (SD) predicted probability of ICU death of 42.4% (+/-28.6). Mean APACHE III score on the day of initiating INO was 107.6 (+/-34.4) with a predicted mortality in the intensive care unit of 72.7% (+/-23.3). Mean PaO(2) to FiO(2) (PF) ratios (+/-SD) prior to, and immediately after, the initiation of INO were 62.6 (+/-28.2) and 111 (+/-65.1), respectively (P < 0.001). The median duration of INO therapy was 41.8 h (interquartile range, 6.3-98.2). Patients with hematological malignancies and acute respiratory failure to whom INO was administered had clinical deterioration since ICU admission. Despite a marked initial improvement in arterial oxygen tension, all patients ultimately died in the intensive care unit, 8 of them within 48 h of initiating INO. Therefore, despite initial improvement in oxygenation, we did not observe any survival benefit to INO in this setting.     

Outcome of older critically ill patients: a matched cohort study

BACKGROUND: Admission of older patients to intensive care units is a controversial issue. OBJECTIVE: To estimate age-associated mortality of critically ill patients. METHODS: A prospective matched cohort study in the Medical-Surgical Intensive Care Unit of a tertiary hospital was conducted. We included 100 consecutive patients older than 70 years admitted to the intensive care unit (cases) and 100 patients younger than 70 years (controls). The matching criterion was the severity of illness at admission to the intensive care unit as estimated by the simplified acute physiological score (SAPS II) without including age in its calculation. RESULTS: Mortality in the intensive care unit was higher, but not statistically significant, in the older group: 26% vs. 19% (p = 0.23). Patients older than 70 years had a longer duration of mechanical ventilation (median 7 vs. 3 days) and longer stay in the intensive care unit (median 8 vs. 5 days). There were no differences in organ dysfunctions, except for a higher incidence of respiratory failure in the older group (p < 0.001). The use of invasive procedures was similar in both groups. There were more orders for the withholding/withdrawal of treatment in patients older than 70 years (9 vs. 3%, p = 0.07). CONCLUSION: In our study, age was not related with a significant higher mortality. In the older patients included in our study the survival was greater than 70% with a similar resource utilization except for a longer stay in the intensive care unit.     

Precedents for meaningful recovery during treatment in a medical intensive care unit. Outcome in patients with hematologic malignancy

The medical records of 77 patients with hematologic malignancy who were admitted to a medical intensive care unit over a 21-month period were reviewed. The overall hospital mortality rate was 80 percent. Sixteen patients (21 percent) were discharged from the intensive care unit but eventually died in the hospital. The cause of death was the result of a new problem in only three of these 16 patients. Hypotension (shock) and acute respiratory failure were the reasons prompting admission to the intensive care unit in 75 percent, but death in the intensive care unit was almost always the result of intractable hypotension rather than refractory hypoxemia. Only four of 52 patients who required mechanical ventilation left the hospital. In all four, the duration of ventilatory support was less than five days and the cause of respiratory failure was noninfectious in nature. Factors such as congestive heart failure, leukopenia, and abnormalities in mental status modified the hospital course, but did not alter outcome once prolonged mechanical ventilation became necessary. The data suggest that once acute respiratory failure develops in patients with lymphoma or leukemia, presumably as a result of infection, and mechanical ventilation for more than a relatively brief period is required, the prognosis is uniformly grim. Decisions to limit aggressive therapies is subsets of intensive care patients such as these should be aided by data that show a lack of precedent for meaningful recovery.     

Prognostic scoring for critically ill hospitalized patients

The objective of the study was to validate and refine the APACHE II (acute physiology and chronic health evaluation II) prognostic system in the Indian context. We prospectively collected data on 79 patients admitted in the medical intensive care unit. We have studied APACHE II and 11 other physiological variables and sought to improve the risk prediction by developing a new score to be governed by the rule of thumb at the bed side. The new score included the following five variables: pH and serum albumin at admission and heart rate, bilirubin and Glasgow coma scale at 48 hours. A score below 3.5 was independently associated with a statistically significant increase in the risk of hospital death. This model resulted in a pseudo r2 of 0.43 in comparison to pseudo r2 of 0.02 and 0.12 for APACHE II scores on the day of admission and after 48 hours, respectively.     

QT Dispersion and Prognostication of the Outcome in Acute Cardiotoxicities: A Comparison with SAPS II and APACHE II Scoring Systems

We aimed to evaluate the efficacy of QT dispersion (QTD) in determining the outcome of the patients poisoned by cardiotoxic medications and toxins. Patients who referred to our emergency department (ED) due to acute toxicity with any cardiotoxic medication or toxin and were admitted to medical toxicology intensive care unit (MTICU) were enrolled into the study. A questionnaire containing the demographic characteristics, vital signs, laboratory tests, electrocardiographic (ECG) parameters of the first ECG taken on MTICU or ED admission, simplified acute physiology score (SAPS), and acute physiology and chronic health evaluation (APACHE) score was filled for every single patient. QTD was manually calculated. The patients were divided into two groups of survivors and non-survivors and compared. Although QTD was not significantly different between the survivors and non-survivors (P = 0.8), SAPS II and APACHE II score were so. SAPS and APACHE had the highest sensitivity and specificity in determining the patients’ mortality, respectively. SAPS had the highest sensitivity, and QTD had the highest specificity in predicting the later development of the complications. SAPS II and APACHE II scoring systems are the best systems for prognostication of death in patients with acute cardiotoxic medication-induced poisonings. QTD can be successfully used for the prediction of complications.     

Autoimmune rheumatic diseases in the intensive care unit: experience from a tertiary referral hospital and review of the literature

Autoimmune rheumatic diseases (AIRD) are not uncommon in the general population and up to one third of hospitalized patients with AIRD may need admission to intensive care unit (ICU). This paper describes the causes of admission, the clinical features and outcome of 24 AIRD patients admitted to a medical ICU from a third level hospital. Thirteen patients had systemic lupus erythematosus (54.2%), three rheumatoid arthritis (12.5%), three pulmonary renal syndrome (12.5%), two dermatopolymyositis (8.3%), two scleroderma (8.3%) and one antiphospholipid syndrome (4.2%). The main causes for ICU admission were rheumatic disease flare-up (37.5%), infection (37.5%) and complications derived from rheumatic disease (29.1%). Mortality during ICU stay was 16.7% (four patients). Excluding shock requiring vasopressor support, no statistical difference was found between survivors and nonsurvivors; although there was a trend to higher test severity scores (APACHE II, ODIN) in nonsurvivors. Our results reveal a lower mortality rate in AIRD patients admitted to the ICU than reported previously. Severity scores such as APACHE II are predictors of mortality in patients with AIRD in the ICU.     

Coronavirus Disease 2019 and Liver Injury: A Retrospective Analysis of Hospitalized Patients in New York City

Background and AimsCoronavirus disease 2019 (COVID-19) is a global threat, affecting more than 100 million people and causing over 2 million deaths. Liver laboratory test abnormalities are an extrapulmonary manifestation of COVID-19, yet characterization of hepatic injury is incomplete. Our objective was to further characterize and identify causes of liver injury in patients with COVID-19.MethodsWe conducted a retrospective cohort study of 551 patients hospitalized with COVID-19 at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center between March 1, 2020 and May 31, 2020. We analyzed patient demographics, liver laboratory test results, vital signs, other relevant test results, and clinical outcomes (mortality and intensive care unit admission).ResultsAbnormal liver laboratory tests were common on hospital admission for COVID-19 and the incidence increased during hospitalization. Of those with elevated serum alanine aminotransferase and/or alkaline phosphatase activities on admission, 58.2% had a cholestatic injury pattern, 35.2% mixed, and 6.6% hepatocellular. Comorbid liver disease was not associated with outcome; however, abnormal direct bilirubin or albumin on admission were associated with intensive care unit stay and mortality. On average, patients who died had greater magnitudes of abnormalities in all liver laboratory tests than those who survived. Ischemic hepatitis was a mechanism of severe hepatocellular injury in some patients.ConclusionsLiver laboratory test abnormalities are common in hospitalized patients with COVID-19, and some are associated with increased odds of intensive care unit stay or death. Severe hepatocellular injury is likely attributable to secondary effects such as systemic inflammatory response syndrome, sepsis, and ischemic hepatitis.     

An evaluation of outcome from intensive care in major medical centers

We prospectively studied treatment and outcome in 5030 patients in intensive care units at 13 tertiary care hospitals. We stratified each hospital's patients by individual risk of death using diagnosis, indication for treatment, and Acute Physiology and Chronic Health Evaluation (APACHE) II score. We then compared actual and predicted death rates using group results as the standard. One hospital had significantly better results with 69 predicted but 41 observed deaths (p less than 0.0001). Another hospital had significantly inferior results with 58% more deaths than expected (p less than 0.0001). These differences occurred within specific diagnostic categories, for medical patients alone and for medical and surgical patients combined, and were related more to the interaction and coordination of each hospital's intensive care unit staff than to the unit's administrative structure, amount of specialized treatment used, or the hospital's teaching status. Our findings support the hypothesis that the degree of coordination of intensive care significantly influences its effectiveness.     

Prognostic contributions of the underlying inflammatory disease and acute organ dysfunction in critically ill patients with systemic rheumatic diseases

BackgroundKnowledge about the clinical features, outcomes and predictors of short-term mortality in critically ill patients with systemic rheumatic disease (SRD) requires further characterization.MethodsSingle center retrospective observational cohort study of 149 critically ill patients with SRD followed in a French medical intensive care unit over a 20-year period. Multivariate logistic regression was used to identify predictors of day-30 mortality.ResultsMost patients (63%) had systemic lupus erythematosus, rheumatoid arthritis, or systemic sclerosis. The critical illness usually developed late after the diagnosis of SRD (median time to ICU admission 82 months, IQR [9–175] in the 127 patients with a previous diagnosis of SRD). Two-thirds of patients were taking immunosuppressive drugs to treat their SRD. Reasons for ICU admission were infection (47%), SRD exacerbation (48%), and iatrogenic complications (11%); the most common organ failure was acute renal failure. Thirty-day mortality was 16%. Predictors of 30-day mortality were the LODS score on day 1 (OR 1.3 (1.06–1.48)), bacterial pneumonia (OR 3.8 (1.03–14.25)), need for vasoactive drugs (OR 7.1 (1.83–27.68)), SRD exacerbation (OR 4.3 (1.15–16.53)), and dermatomyositis (OR 9.2 (1.05–80.78)) as the underlying disease. Year of ICU admission was not significantly associated with 30-day survival.ConclusionPatients with SRD are mostly admitted in the ICU with infection or SRD exacerbation, and can be treated with immunosuppressive therapy and life-sustaining interventions with acceptable 30-day mortality. Death is associated with both the severity of the acute medical condition and the characteristics of the underlying SRD.     

Characteristics and prognosis of patients with acute myocardial infarction in relation to whether they were treated in the coronary care unit or in another ward.

The characteristics and the prognosis in 921 consecutive patients with acute myocardial infarction (AMI) admitted to one single hospital are described and related to whether they were treated in the coronary care unit or not. Patients treated in the coronary care unit (n = 779) had a 1-year mortality rate of 26% as compared with 41% for patients treated in general wards (n = 115; p < 0.001) and 74% for patients treated in the intensive care unit (n = 27; p < 0.001). Patients treated outside the coronary care unit had a different risk factor pattern including a higher age and a higher prevalence of a previous cardiovascular disease. Independent clinical risk indicators for death among patients in the coronary care unit were in order of significance, high age (p < 0.001), arrhythmia on admission (p < 0.01), acute congestive heart failure on admission (p < 0.01) and a history of diabetes mellitus (p < 0.05). In patients treated in general wards, the only risk indicator for death was a history of congestive heart failure.     

Prospective evaluation of the risk of upper gastrointestinal bleeding after admission to a medical intensive care unit

One hundred seventy-four patients (179 admissions) were prospectively evaluated for the subsequent occurrence of upper gastrointestinal (“stress”) bleeding after admission to a medical/respiratory intensive care unit. Evidence for either overt or occult gastrointestinal bleeding developed in 25 (14 percent). The group of bleeders had a higher mortality (64 percent versus 9 percent), duration of intensive care unit stay (median 14.2 versus 4.2 days), number of patients requiring mechanical ventilatory support (84 percent versus 26 percent), and duration of such support for those who required it (median 9.5 versus 4.2 days) than the group who did not bleed. In three patients, death was related to bleeding. Upon patients' admission to the intensive care unit, diagnoses of an acute respiratory illness (but not specifically chronic obstructive pulmonary disease), a malignancy, or sepsis were more common among those who subsequently bled. Of factors tested, a coagulopathy and the need for mechanical ventilation were most strongly associated with the risk of bleeding. Other factors did not add to the risk once these two were taken into account. Among patients receiving mechanical ventilation, the risk of overt bleeding was particularly low for those who required such support for less than five days (only 3 percent). It is concluded that (1) significant upper gastrointestinal bleeding occurring after medical intensive care unit admission is an uncommon event, and (2) prolonged mechanical ventilation and/or the presence of a coagulopathy are the most potent risk factors. Medical patients with either of the latter conditions are most likely to benefit from prophylaxis regimens against “stress”-induced upper gastrointestinal bleeding.     

Prediction of outcome from critical illness. A comparison of clinical judgment with a prediction rule

Quantitative methods to enhance clinical judgment would be of tremendous benefit to physicians caring for the critically ill. The ability of physicians to predict outcome is a logical standard on which to base the prospective evaluation of a prediction rule intended for this clinical use. The APACHE (acute physiology and chronic health evaluation)-II score was compared with critical care physicians' prediction of outcome for a group of patients in a medical intensive care unit. Physicians were significantly better in predicting outcome in the critically ill. However, the APACHE-II score was still a good predictor of outcome in the intensive care unit and, according to analysis using Bayes' theorem, might still be a useful test to support physicians' judgment, especially in patients with a predicted mortality risk of less than 30%.     

Intensive care for very elderly patients: outcome and risk factors for in-hospital mortality.

OBJECTIVES: To evaluate outcome and risk factors, particularly the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system, for in-hospital mortality in very elderly patients after admission to an intensive care unit (ICU). METHODS: Retrospective chart review of patients > or =85 years admitted to the ICU. We recorded age, sex, previous medical history, primary diagnosis, date of admission and discharge or death, APACHE II score on admission, use of mechanical ventilation and inotropics, and complications during ICU admission. RESULTS: 104 patients > or =85 years (1.3% of all ICU admissions) were studied. The ICU and in-hospital mortality rates for these patients were 22 and 36% respectively. Factors correlated with a greater in-hospital mortality were: an admission diagnosis of acute respiratory failure (chi2; P = 0.007), the use of mechanical ventilation (chi2; P = 0.00005) and inotropes (chi2; P = 0.00001), complications during ICU admission (chi2; P = 0.004), in particular acute renal failure (chi2; P = 0.005), and an APACHE II score > or =25 (chi2; P = 0.001). The APACHE II scoring system and the use of inotropes were independently correlated with mortality. CONCLUSION: ICU and in-hospital mortality are higher in very elderly patients, particularly in those with an APACHE II score > or =25. The most important predictors of mortality are the use of inotropes and the severity of the acute illness.