Predicting mortality in intensive care unit patients infected with Klebsiella pneumoniae: A retrospective cohort study

IntroductionAlthough several models to predict intensive care unit (ICU) mortality are available, their performance decreases in certain subpopulations because specific factors are not included. Moreover, these models often involve complex techniques and are not applicable in low-resource settings. We developed a prediction model and simplified risk score to predict 14-day mortality in ICU patients infected with Klebsiella pneumoniae.MethodologyA retrospective cohort study was conducted using data of ICU patients infected with Klebsiella pneumoniae at the largest tertiary hospital in Northern Vietnam during 2016–2018. Logistic regression was used to develop our prediction model. Model performance was assessed by calibration (area under the receiver operating characteristic curve-AUC) and discrimination (Hosmer-Lemeshow goodness-of-fit test). A simplified risk score was also constructed.ResultsTwo hundred forty-nine patients were included, with an overall 14-day mortality of 28.9%. The final prediction model comprised six predictors: age, referral route, SOFA score, central venous catheter, intracerebral haemorrhage surgery and absence of adjunctive therapy. The model showed high predictive accuracy (AUC = 0.83; p-value Hosmer-Lemeshow test = 0.92). The risk score has a range of 0–12 corresponding to mortality risk 0–100%, which produced similar predictive performance as the original model.ConclusionsThe developed prediction model and risk score provide an objective quantitative estimation of individual 14-day mortality in ICU patients infected with Klebsiella pneumoniae. The tool is highly applicable in practice to help facilitate patient stratification and management, evaluation of further interventions and allocation of resources and care, especially in low-resource settings where electronic systems to support complex models are missing.     

Incidence and outcome from adult cardiac arrest occurring in the intensive care unit: A systematic review of the literature

Background

Significant amount of data on the incidence and outcome of out-of-hospital and in-hospital cardiac arrest have been published. Cardiac arrest occurring in the intensive care unit has received less attention.

Aims

To evaluate and summarize current knowledge of intensive care unit cardiac arrest including quality of data, and results focusing on incidence and patient outcome.

Sources and methods

We conducted a literature search of the PubMed, CINAHL and Cochrane databases with the following search terms (medical subheadings): heart arrest AND intensive care unit OR critical care OR critical care nursing OR monitored bed OR monitored ward OR monitored patient. We included articles published from the 1st of January 1990 till 31st of December 2012. After exclusion of all duplicates and irrelevant articles we evaluated quality of studies using a predefined quality assessment score and summarized outcome data.

Results

The initial search yielded 794 articles of which 780 were excluded. Three papers were added after a manual search of the eligible studies’ references. One paper was identified manually from the literature published after our initial search was completed, thus the final sample consisted of 18 papers. Of the studies included thirteen were retrospective, two based on prospective registries and three were focused prospective studies. All except two studies were from a single institution. Six studies reported the incidence of intensive care unit cardiac arrest, which varied from 5.6 to 78.1 cardiac arrests per 1000 intensive care unit admissions. The most frequently reported initial cardiac arrest rhythms were non-shockable. Patient outcome was variable with survival to hospital discharge being in the range of 0–79% and long-term survival ranging from 1 to 69%. Nine studies reported neurological status of survivors, which was mostly favorable, either no neurological sequelae or cerebral performance score mostly of 1–2. Studies focusing on post cardiac surgery patients reported the best long-term survival rates of 45–69%.

Conclusions

At present data on intensive care unit cardiac arrest is quite limited and originates mostly from retrospective single center studies. The quality of data overall seems to be poor and thus focused prospective multi-center studies are needed.     

Organ function during early acute renal failure does not predict survival in long-term intensive care

Objective To examine outcome in relation to organ function variables during early acute renal failure (ARF).Design Retrospective inception cohort.Setting General intensive care unit (ICU).Patients 69 consecutive ARF cases verified to have a creatinine clearance below 50 ml/min with no history of previous renal disease.Main outcome measure ICU survival.Measurements and results Septic severity score (SSS), creatinine clearance, thrombocyte count, bilirubin concentration, cardiac inotropic support, PaO₂/FIO₂ ratio and oliguria were measured. No differences related to outcome were observed in patients surviving more than 7 days after ARF diagnosis. Patients dying within 7 days of ARF had a significantly higher (worse) SSS. Organ dysfunction was established at the time of ICU admission in the majority of cases.Conclusion The organ function variables tested in this study are of limited predictive value during the early stage of ARF.     

A model for identifying patients who may not need intensive care unit admission

Purpose

This study presents a new model for identifying patients who might be too well to benefit from intensive care unit (ICU) care.

Patients and Methods

Intensive care unit admissions in 2002 to 2003 were used to develop a model to predict whether patients monitored on day one would receive one or more of 33 subsequent active life-supporting treatments. Accuracy was assessed by testing the model in a subsequent cohort of admissions in 2004 to 2006. We then assessed the frequency of active treatment among monitor patients at a low (<10%) risk for active life-supporting therapy on ICU day 1.

Results

Among 28 847 ICU monitor admissions in 2004 to 2006, 3153 patients (11.0%) were predicted to receive active treatment; 3296 (11.5%) actually did. There were 17 720 admissions with a low (<10%) risk for receiving subsequent active life-supporting treatment; 1238 (7.0%) received subsequent active treatment. Hospital mortality (2.5%) and mean ICU stay (1.8 days) suggests that most of these patients did not require ICU care.

Conclusions

The outcome for low-risk monitor patients suggest they may be too well to benefit from intensive care. The frequency of low-risk monitor admissions provides a measure of ICU resource use. Improved resource use and reduced costs might be achieved by strategies to provide care for these patients on floors or intermediate care units.     

Organ donation within the intensive care unit: A retrospective audit

BackgroundDespite many Australians supporting organ donation, national posthumous organ donation rates have not increased as expected over the last three decades. Little is known about the barriers to organ donation for patients in intensive care that meet the criteria for organ donation.ObjectiveThe aim of this study was to describe the characteristics of patients identified as potentially suitable for organ donation and to explore the variables associated with the success, or failure, of solid organ donation within the context of an Australian public hospital intensive care unit (ICU).MethodsA retrospective audit examined electronic records of 280 potential organ donors aged 18–80 years, admitted into the ICU between 1 July 2012 and 30 June 2016. Data extracted from three separate electronic hospital databases were amalgamated for analysis.ResultsOf the 280 potential organ donors identified, conversations with families of 182 (65%) patients resulted in their agreement to organ donation. Consent to organ donation was most often provided by the patient's spouse (65, 35.7%); however, only 63.7% (n = 116) were successful organ donors. The remaining 36.3% (n = 66) of patients did not donate organs for medical reasons. Compared with those who did not donate, the typical organ donor was significantly younger (M 49.9 years, p = 0.020), Australian-born (p = 0.031), and had a shorter length of ICU stay (M 64.9 h, p = 0.002). The most frequently donated organs were kidneys (103, 88.8%), lungs (59, 50.9%), and livers (52, 44.8%).ConclusionThis study provided insights into patient, family, and organisational factors contributing to the success of organ donation outcomes in the ICU. Two factors that adversely impacted donation outcomes were the following: (1) the family did not consent to organ donation on behalf of the patient and (2) consent was provided, but donation did not proceed for medical reasons. Although the focus on the consenting process has been raised, this study highlights the additional impact of medical suitability on rates of organ donation. Family members may experience significant disappointment after consent that may have repercussions on their health and also future donation considerations. This study also highlighted some deficiencies in the databases that, if addressed, could better inform organisational processes in the consent and support of those making decisions about consent.     

Plasma cortisol is often decreased in patients treated in an intensive care unit

Objective: To investigate the prevalence of adrenal hypofunction, as assessed by plasma cortisol (p-cortisol) and its relationship to clinical events. Design: Prospective, consecutive. Setting: General intensive care unit in a university hospital. Patients: Fifty-five patients (34 men and 21 women) were studied (surgery 40 patients, hemodialysis 5, ventilator treatment 45, sepsis 21). Methods: Morning basal levels of p-cortisol were determined. Previous reports define adrenal insufficiency to be present if p-cortisol under stressful conditions is lower than either 400 or 500 nmol/l. The tetracosactoid test (250 μg Synacthen) was performed in 16 patients and urinary 24-h excretion of cortisol in 24 (none on corticosteroid treatment). Results: Median p-cortisol was 550 nmol/l (range 20–1764). In 36 % of patients p-cortisol was lower than 400 nmol/l and in 47 % lower than 500 nmol/l. There was a significantly increased probability (P < 0.05) of p-cortisol being below 400 nmol/l in patients admitted due to trauma or cerebral disorder and in patients on ventilator therapy or on mannitol. Thirty minutes after tetracosactoid administration p-cortisol response was lower than 200 nmol/l in 56 % of the patients. Conclusions: Several patients had low p-cortisol and attenuated responses to tetracosactoid, indicative of adrenal insufficiency. There seem to be certain risk factors for adrenal hypofunction which may justify more frequent use of physiological doses of corticosteroid in selected patients Received: 5 February 1999 Final revision received: 16 December 1999 Accepted: 21 December 1999     

Short-term and long-term mortality in very elderly patients admitted to an intensive care unit

Objective To report short-term and long-term mortality of very elderly ICU patients and to determine independent risk factors for short-term and long-term mortalityDesign and setting Retrospective cohort study in the medical/surgical ICU of a tertiary university teaching hospital.Patients 578 consecutive ICU patients aged 80 years or older.Results Demographic, physiological, and laboratory values derived from the first 24 h after ICU admission. ICU mortality of unplanned surgical (34.0%) and medical patients (37.7%) was higher than that of planned surgical patients (10.6%), as was post-ICU hospital mortality (26.5% and 29.7% vs. 4.4%). Mortality 12 months after hospital discharge, including ICU and hospital mortality, was 62.1% in unplanned surgical and 69.2% in medical patients vs. 21.6% in planned patients. Only median survival of planned surgical patients did not differ from survival in the age- and gender-matched general population. Independent risk factors for ICU mortality were lower Glasgow Coma Scale score, higher SAPS II score, the lowest urine output over 8 h, abnormal body temperature, low plasma bicarbonate levels, and higher oxygen fraction of inspired air. High urea concentrations and admission type were risk factors for hospital mortality, and high creatinine concentration was an independent risk factor for 12-month mortality.Conclusion Mortality in very elderly patients after unplanned surgical or medical ICU admission is higher than after planned admission. The most important factors independently associated with ICU mortality were related to the severity of illness at admission. Long-term mortality was associated with renal function.This article is discussed in the editorial available at:     

重症监护病房铜绿假单胞菌的耐药性监测

目的了解我院重症监护病房(ICU)患者铜绿假单胞菌耐药谱的变化。方法应用回顾性调查方法对ICU感染者两年送检标本中分离的116株铜绿假单胞菌药敏试验进行分析。结果铜绿假单胞菌对阿米卡星,头孢他定,哌拉西林,头孢哌酮,亚胺培能,哌拉西林/他唑巴坦的敏感率均在50%以上;对复方磺胺的敏感率最低约在3.6%;铜绿假单胞菌对常用的13种抗生素的耐药率呈上升趋势。结论铜绿假单胞菌耐药现象严重,ICU应注意铜绿假单胞菌耐药性监测。     

Interhospital transfer of critically ill patients: demographic and outcomes comparison with nontransferred intensive care unit patients

PURPOSE: We examined the association between access to intensive care services and mortality in a cohort of critically ill patients. MATERIALS AND METHODS: We conducted an observational study involving 6298 consecutive admissions to the intensive care units (ICUs) of a tertiary care hospital. Data including demographics, admission source, and outcomes were collected on all patients. Admission source was classified as "transfer" for patients admitted to the ICU from other hospitals, "ER" for patients admitted from the emergency room, and "ward" for patients admitted from non-ICU inpatient wards. RESULTS: Transfer patients had higher crude ICU and hospital mortality rates compared with emergency room admissions (crude odds ratio [OR], 1.51; 95% confidence interval [CI], 1.32-1.75). After adjusting for age, sex, diagnosis, comorbidities, and acute physiology scores, the difference in ICU mortality remained significant (OR, 1.30; 95% CI, 1.09-1.56); however, hospital mortality did not (OR, 1.19; 95% CI, 1.00-1.41). Compared with ward patients, transfer from other hospitals was associated with lower hospital mortality after adjusting for severity of illness and other case-mix variables (OR, 0.81; 95% CI, 0.68-0.95). CONCLUSIONS: We found some evidence to suggest that differential access to intensive care services impacts mortality within this case mix of patients. These findings may have implications for current efforts to centralize and regionalize critical care services.     

Clinical profile, intensive care unit course, and outcome of patients admitted in intensive care unit with dengue

Purpose

The purpose of the study was to assess the clinical profile and course of dengue patients admitted to the intensive care unit (ICU) and to identify factors related to poor outcome.

Methods

All patients with dengue admitted to ICU over 2.5 years were included prospectively. Severity of illness was assessed by the Acute Physiology and Chronic Health Evaluation (APACHE) II score, and organ failure was determined by the Sequential Organ Failure Assessment score. Primary outcome measure was 28-day mortality. Logistic regression analysis was performed to identify factors predicting mortality.

Results

Data from 198 patients were analyzed. Mean age was 39.56 ± 17.1 years, and 61.1% were male. The commonest complaints were fever (96%) and rash (37.9%). Mean admission APACHE II and Sequential Organ Failure Assessment scores were 7.52 ± 7.8 and 4.52 ± 3.4, respectively. The commonest organ failure was coagulation (43.4%) followed by respiratory failure (13.1%). Vasopressors were required by 11.6%; and dialysis and mechanical ventilation were required by 7.6% and 9.1%, respectively. Mortality was 12 (6.1%); and on multivariate analysis, APACHE II score (odds ratio, 1.781; 95% confidence interval, 0.967-3.281; P = .048) could independently predict mortality.

Conclusions

Patients with dengue fever may require ICU admission for organ failure. Outcome is good if appropriate aggressive care and organ support are instituted. Admission APACHE II score may predict patients at higher risk of death.     

重症监护病房临床病原微生物送检实证分析

目的 调查重症监护病房(ICU)临床微生物标本采样送检和初始抗菌治疗用药情况,为促进抗菌药物合理使用提供依据.方法 回顾性调查2012年7月1日至12月31日和2013年7月1日至12月31日从浙江大学医学院附属第二医院ICU出院的所有病例,选取入住ICU时有确切感染证据并在当日接受抗菌治疗病例,对患者感染状况、初始抗菌药物使用、微生物标本送检信息和病原检查结果并进行分析.结果 841例出院病例中,443例入住ICU时有确切感染证据并接受初始抗菌治疗,其中仅30例(6.8％)在初始抗菌治疗前已有病原学送检结果.369例入住ICU时有感染部位的微生物样本可采,360例(97.6％)在入住ICU 3 d内有送检.送检标本以痰最多(占56.4％),其次为血标本17.4％,但仅有119例(33.1％)在首剂抗菌药物使用前完成标本采样.进一步分析接受初始广谱抗菌治疗的269例患者,入住ICU头3d也仅有33.5％病例是在首剂抗菌药物使用前完成标本采样;与使用前采样相比,首剂抗菌药物使用后采样培养的鲍曼不动杆菌、嗜麦芽窄食单胞菌和洋葱伯克霍尔德菌等耐药菌检出率明显升高(P＜0.05);金黄色葡萄球菌、肠杆菌科细菌等检出率在首剂抗菌药物使用前后采样比较差异无统计学意义.结论 收住ICU的感染患者初始经验性抗菌治疗前病原学证据缺少,微生物标本送检率虽高但普遍在首剂抗菌药物使用后采样,且以痰等非无菌部位标本为主,降低了病原检查结果的可靠性.     

重症监护病房患者病原菌菌谱及耐药性分析

目的 了解我院重症监护室（ICU）患者病原菌分布及耐药情况,为临床的诊断和合理用药提供实验室依据.方法 对2008年6月至2010年12月我院ICU患者送检的各种标本检出的病原菌采用VETIK32全自动细菌鉴定仪进行细菌鉴定和药敏分析,并结合纸片扩散法（K-B法）进行药敏试验和耐药性分析.结果 共分离出病原菌329株,其中革兰阴性菌227株（69.0%）,革兰阳性菌95株（28.88%）,真菌7株（2.13%）,其中常见致病菌前5位病原菌为鲍曼不动杆菌56株,占总病原菌17.02%;铜绿假单胞菌52株,占总病原菌15.81%;肺炎克雷伯菌49株,占总病原菌14.89%;金黄色葡萄球菌39株,占总病原菌11.85%;凝固酶阴性葡萄球菌38株,占总病原菌11.55%.大多数病原菌对青霉素、氨苄西林耐药,而对万古霉素、亚胺培南等药物敏感性较好,未发现耐万古霉素金黄色葡萄球菌和耐万古霉素凝固酶阴性葡萄球菌.结论 在ICU内细菌以革兰阴性杆菌为主,药敏试验呈多重耐药,治疗上应根据药敏结果选择敏感抗菌药物,避免滥用.     

Person-centred care among intensive care unit nurses: A cross-sectional study

ObjectivePractising person-centred care is crucial for nurses in the intensive care unit, as patients have high physical and psychological care needs. We aimed to identify the predictors of person-centred care among nurses working in intensive care settings.MethodsIn this cross-sectional study, 188 intensive care unit nurses at four tertiary hospitals in two cities of South Korea were included. They completed self-reported questionnaires on emotional intelligence, compassion satisfaction, secondary traumatic stress, burnout, and person-centred care. Emotional intelligence was measured using the Korean version of the Wong and Law’s emotional intelligence scale. Compassion satisfaction, secondary traumatic stress, and burnout were measured by the Professional Quality of Life questionnaire (version 5). Person-centred care was measured using the person-centred critical care nursing scale.ResultsMultiple regression identified compassion satisfaction (β = 0.49, p <.001) as the most powerful predictor of person-centred care, followed by emotional intelligence (β = 0.21, p =.004) and intensive care unit career length (β = 0.17, p =.021). These three variables accounted for 31.0 % of the variance in person-centred care.ConclusionsThis study highlights the importance of career length, emotional intelligence, and compassion satisfaction in the promotion of person-centred care among intensive care unit nurses. Nursing management should contemplate specific measures to reduce turnover among experienced intensive care unit nurses and to enhance the factors that promote person-centred care, such as compassion satisfaction and emotional intelligence.     

Clinical decision-making in the intensive care unit: A concept analysis

AimTo operationally define clinical decision-making as it relates to intensive care unit nursing.BackgroundClinical decision-making is an intricate cognitive process that is demanding on intensive care nurses due to the severity of their patients’ illnesses, consistent exposure to high-stakes situations, and prevalent patient mortality. When compromised, it can lead to adverse patient events. However, clinical decision-making specific to the intensive care unit is a concept seldom defined in nursing research.DesignConcept analysis.MethodsUsing Walker and Avant’s eight-step method, nursing databases were searched for studies between 1980 and 2022 describing the antecedents, defining attributes, consequences, and empirical referents of clinical decision-making in the intensive setting.FindingsIntensive care unit clinical decision-making is a complex cognitive process in which nurses recognize a clinical problem in their patient and respond promptly by implementing interventions to improve their patient’s rapidly and frequently changing health status to a more favorable condition in an intensive care setting. The defining attributes are: assessment of the patient situation, prompt recognition of cues, efficient comprehension of patient data abnormalities, prior knowledge and experience, prompt response to the clinical problem(s), colleague collaboration, formulation of interventions to treat clinical problem(s), and appraisal of risks/benefits.ConclusionIntensive care unit clinical decision-making is a skill that is different from traditional clinical decision-making in nursing. Prompt action characterizes this concept due to the unstable health status of these patients. More research on this concept is needed to enhance nurse performance and patient outcomes in intensive care.Implications for clinical practiceA definition of this concept opens doors for potential studies on promoting effective decision-making among intensive care nurses. This can improve the safety and outcomes of critically ill patients. Additionally, it generates new questions regarding how nursing schools and hospital orientation programs can promote and develop competent decision-making skills in future intensive care nurses.     

Bowel management in the intensive care unit

The area of bowel care in the intensive care unit (ICU) is often overlooked in the holistic care of the critically ill individual. With the primary concern of optimising patients to preserve life the problem of bowel care has been given less priority. The guidelines included within this service improvement paper offer a simple approach to bowel care management with the use of an algorithm and visual display score to be used in conjunction with the algorithm. This was developed in the intensive care unit of the Royal Free Hospital, London and is presently in use.     

Risk factors and outcomes of sepsis-associated delirium in intensive care unit patients: A secondary data analysis

ObjectiveTo identify the risk factors of sepsis-associated delirium and determine their effect on intensive care unit adult patient outcomes.DesignA secondary analysis of data from system development studies.SettingKorean intensive care unit patients in a university hospital who were diagnosed with sepsis.MethodsThe risk factors for sepsis-associated delirium were classified into patient factors and sepsis clinical features and were analysed using hierarchical logistic regression analysis. Outcomes included in-hospital mortality, 30-day in-hospital mortality, duration of mechanical ventilation, length of stay in the intensive care unit, length of hospital stay, total medical expenses, discharge placement, re-hospitalisation and visits to the emergency department after discharge.ResultsThe risk factor for sepsis-associated delirium including patients aged 65 ≥years, dependent activity and high nursing needs (patient factors), low level of consciousness, tachypnoea, and thrombocytopaenia (clinical features of sepsis). Use of vasopressors/inotropes and albumin decreased the risk of sepsis-associated delirium. Mechanical ventilation duration was prolonged and discharge to skilled nursing facilities was increased by sepsis-associated delirium.ConclusionsThe risk factors for sepsis-associated delirium increased as the severity of condition for patients with sepsis increased. Early identification of risk factors associated with sepsis-associated delirium may improve patient outcomes.     

Outcome of oncology patients in the pediatric intensive care unit

We evaluated the outcome of oncology patients in the Pediatric Intensive Care Unit (PICU) from a total of 72 consecutive admissions. Severity of illness and quantity of care were measured by the Physiologic Stability Index (PSI) and the Therapeutic Intervention Scoring System (TISS), respectively. The overall mortality was 51% and was especially high in patients admitted for acute organ system failure (OSF)-66%. Acute respiratory failure was the most frequent OSF (73%) and the most common cause for PICU admission. A poor outcome was associated with severe leucopenia (<1000 WBC/mm³, 91% mortality), acute renal failure (94% mortality) and central nervous system deterioration (83% mortality). When the outcome was predicted using a quantitative algorithm the observed mortality was significantly higher than the predicted for all admissions with a PSI higher than 5. Improved scoring systems are required to enable characterization of pediatric cancer patients admitted to the PICU.