Background While enteral feeding intolerance (EFI) is associated with worse clinical outcomes in critically ill patients, the relationship between the number of days of EFI and mortality outcomes remains unclear.
Methods We retrospectively analyzed adult patients admitted to the medical intensive care unit (ICU) with septic shock at a tertiary referral center. EFI was defined as the presence of vomiting, abdominal distension, pain, diarrhea, or radiographic evidence of ileus. EFI status was assessed daily, and we evaluated the prognostic impact of total number of EFI days during the first 3 days of enteral feeding on clinical outcomes.
Results A total of 94 patients were included in the analysis, with 77 (81.9%) experiencing EFI. During the first 3 days of enteral feeding, 25 patients (26.6%) experienced EFI for 1 day, 22 patients (23.4%) experienced EFI for 2 days, and 30 patients (31.9%) experienced EFI for all 3 days. The total number of EFI days was identified as an independent risk factor of 90-day mortality (adjusted hazard ratio, 1.400; 95% CI 1.021–1.919). Higher total EFI days was significantly associated with increased ICU mortality (P for trend=0.036), in-hospital mortality (P for trend=0.007), 30-day mortality (P for trend=0.004), and 90-day mortality (P for trend=0.006).
Conclusions An increase in the total number of EFI days was significantly associated with mortality outcomes in patients with septic shock, suggesting that EFI may serve as a useful indicator for predicting outcomes in this population.
Background The design of intensive care units (ICUs) is increasingly acknowledged as a crucial factor affecting patient outcomes. Transitioning from multi-bed patient rooms (MPRs) to single-bed patient rooms (SPRs) aims to improve infection control, patient privacy, and quality of care. However, concerns remain regarding potential patient isolation and reduced staff situational awareness. This study aims to evaluate clinical outcomes in SPR-structured ICUs compared to mixed SPR and MPR ICUs.
Methods This multicenter retrospective cohort study was conducted across three university-affiliated tertiary hospitals between April 2022 and August 2023. The study population included ICU patients aged ≥18 years, excluding those admitted to cardiac and neonatal ICUs. Outcomes assessed included ICU mortality and severity scores based on Simplified Acute Physiology Score 3 and Acute Physiology and Chronic Health Evaluation II scores.
Results This study included 3,179 ICU patients across three sites: site A consisted exclusively of SPRs, while sites B and C had mixed SPR and MPR arrangements. ICU mortality rates were 8.3%, 15.2%, and 9.7% for sites A, B, and C, respectively (P<0.001). Propensity score matching and logistic regression analysis demonstrated that SPRs were associated with significantly reduced ICU mortality (adjusted odds ratio, 0.54; 95% CI, 0.40–0.73).
Conclusions SPRs were associated with a protective effect, reducing ICU mortality. Clinical outcomes in ICUs appear to be influenced by structural design improvements alongside other clinical factors.
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Background Acute respiratory failure (ARF) is the leading cause of hospitalization and is associated with in-hospital mortality. This study aimed to elucidate the epidemiology and clinical outcomes of ARF.
Methods We retrospectively screened patients admitted to three hospitals in South Korea between January 2018 and December 2022. We included individuals aged 18 years, diagnosed with either type 1 ARF (arterial oxygen partial pressure [PaO2] <60 mm Hg) or type 2 ARF (arterial carbon dioxide partial pressure (PaCO2) >45 mm Hg) with a pH of <7.35, or diagnosed with the combined-type ARF.
Results Among the 768,700 hospitalized patients, 33,278 (4.3%) developed ARF. The most common cause of ARF was sepsis (15,757 patients, 47.3%), and the most frequent comorbidity was malignancy (15,403 patients, 43.6%). Among ARF patients, 15,671 (47.1%) required intensive care unit transfer, while 8,980 (27.0%) experienced in-hospital mortality. Over 5 years, the proportion of ARF patients aged 80 years and older has shown a consistent annual increase (coefficient, 0.085 and Ptrend <0.001). Concurrently, the in-hospital mortality rate exhibited an upward trend, increasing from 25.5% in 2018 to 29.3% in 2022 (coefficient, 1.017 and Ptrend<0.001). Among the respiratory support methods used for patients with ARF over the 5-year period, high-flow nasal cannula usage steadily increased (coefficient, 4.137 and Ptrend<0.001), whereas the use of invasive mechanical ventilation declined (coefficient, –0.983 and Ptrend<0.001).
Conclusions ARF frequency and in-hospital mortality rates are increasing, driven by various etiologies. Despite these trends, research on the epidemiology and individualized treatments for older patients is limited, highlighting the need for nationwide prospective multicenter studies.
Background Sepsis and septic shock are life-threatening global health challenges associated with high mortality rates. Early identification of high-risk patients is critical for improving outcomes. In the present study, the association between the neutrophil-to-lymphocyte-to-albumin ratio (NLAR) and mortality in septic patients was evaluated.
Methods A retrospective study was performed at a tertiary hospital in Vietnam. Patients ≥18 years of age diagnosed with sepsis or septic shock based on the Sepsis-3 criteria were included. Exclusion criteria included recent corticosteroid use within 7 days, autoimmune diseases, hematological disorders, and active cancer within 5 years. NLAR was calculated from complete blood counts and albumin levels within the first 24 hours of intensive care unit admission. Receiver operating characteristic (ROC) curves were used to determine the predictive ability of NLAR for in-hospital mortality.
Results The present study included 141 patients with a mean age of 72 years. Non-survivors were significantly older with higher rates of mechanical ventilation. NLAR was significantly elevated in non-survivors compared with survivors (0.88 [0.57–1.24] vs. 0.44 [0.28–0.77], P<0.001). In ROC analysis, the area under the curve for NLAR was 0.70 (P<0.001). Using a cutoff value of 0.56, NLAR showed a sensitivity of 77.8% and a specificity of 61.5% for predicting in-hospital mortality.
Conclusions Elevated NLAR on admission was associated with a higher mortality rate in sepsis patients. NLAR could be used as an early prognostic marker for sepsis mortality.
Background The mortality of severe dengue infections is approximately 23%. In the management of dengue shock syndrome (DSS), aggressive fluid resuscitation is recommended. The primary objective of our study was to assess the factors associated with 30-day mortality in DSS patients.
Methods Adult patients >18 years old, who were admitted with DSS were included. DSS was diagnosed in patients who required vasopressors or had lactic acidosis >4 mmol/L. Patients were divided into three different groups based on cumulative fluid balance at death or extubation: group I (<3.5 L), group II (3.5–8.0 L), and group III (>8.0 L).
Results A total of 135 patients with DSS was included, with an overall 30-day mortality of 74.8%. The average Sequential Organ Failure Assessment (SOFA) score on intensive care unit admission was 12.2. Mechanical ventilation was required in 112 patients (83.0%), with 61 patients (45.2%) being intubated without a noninvasive ventilation trial. Respiratory failure was the most common reason for requiring intubation (65 patients, 48.2%). In survivors, the median cumulative fluid balance was 1,493 ml (interquartile range [IQR], 0–4,501 ml), whereas that in the mortality group was 7,797 ml (IQR, 3,700–13,600 ml). On multivariate analysis, SOFA score (odds ratio [OR], 1.220; 95% CI, 1.011–1.472; P=0.038) and having received >8.0 L cumulative fluid balance (OR, 6.682; 95% CI, 1.808–24.689; P=0.004) were associated with increased risk of mortality.
Conclusions DSS patients have high mortality rates. High SOFA scores and >8.0 L cumulative fluid balance may indicate worse outcomes.
Background Pediatric acute respiratory distress syndrome (PARDS) has a mortality rate of up to 75%, which can be up to 90% in high-risk patients. Even with the use of advanced ventilation strategies, mortality remains unacceptably high at 40%. Airway pressure release ventilation (APRV) mode is a new strategy in PARDS. Our aim was to evaluate whether use of APRV mode in severe PARDS was associated with reduced hospital mortality compared to other modes of ventilation.
Methods This was a retrospective comparative study using data from case files in a pediatric intensive care unit of a university-affiliated tertiary-care hospital. The study period (January 2014 to December 2019) covered three years before routine use of APRV mode to three years after its implementation. We compared severe PARDS patients in two groups: The APRV group (who received APRV as rescue therapy after failing protective ventilation); and The Non-APRV group, who received other modes of ventilation.
Results A total of 24 patients in each group were analyzed. Overall in-hospital mortality in the APRV group was 79% versus 91% in the Non-APRV group. In-hospital mortality was significantly lower in the APRV group (univariate analysis: hazard ratio [HR], 0.27; 95% CI, 0.14–0.52; P=0.001 and multivariate analysis: HR, 0.03; 95% CI, 0.005–0.17; P=0.001). Survival times were significantly longer in the APRV group (median time to death: 7.5 days in APRV vs. 4.3 days in non-APRV; P=0.001).
Conclusions Use of rescue APRV mode in severe PARDS may yield lower mortality rates and longer survival times.
Background This study investigated the relationship between initial lactate levels and both mortality and morbidity in critically ill pediatric trauma patients requiring intensive care.
Methods This retrospective study at tertiary center’s pediatric intensive care unit from January 2020 to June 2024 aimed to characterize trauma patients and assess admission lactate levels' prognostic value.
Results A total of 190 critically ill pediatric trauma patients were included in the study. The mortality rate was 7.9%, with most deaths occurring within the first 48 hours of admission. Initial lactate levels ≥6.9 mmol/L demonstrated moderate predictive power (area under the curve [AUC], 0.878) for mortality. Pediatric Risk of Mortality III (PRISM III) score showed good predictive ability (AUC, 0.922), while Pediatric Trauma Scores exhibited variable predictive performance (AUC, 0.863). Higher initial lactate levels were significantly associated with severe brain injury, the need for intubation, and an increased incidence of thoracic or abdominal injuries.
Conclusions Initial lactate levels and PRISM III score are effective predictors of mortality in critically ill pediatric trauma patients. Lactate levels ≥5 mmol/L upon admission should prompt close monitoring and consideration of aggressive management strategies.
Background In this study, we aimed to compare the in-hospital mortality of patients with cancer who experienced acute abdominal complications that required emergent surgery in open (treatment decisions made by the primary attending physician of the patient's admission department) versus closed (treatment decisions made by intensive care unit [ICU] intensivists) ICUs.
Methods This retrospective, single-center study enrolled patients with cancer admitted to the ICU before or after emergency surgery between November 2020 and September 2023. Univariate and logistic regression analyses were conducted to explore the associations between patient characteristics in the open and closed ICUs and in-hospital mortality.
Results Among the 100 patients (open ICU, 49; closed ICU, 51), 23 died during hospitalization. The closed ICU group had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, vasopressor use, mechanical ventilation, and preoperative lactate levels and a shorter duration from diagnosis to ICU admission, surgery, and antibiotic administration than the open ICU group. Univariate analysis linked in-hospital mortality and APACHE II score, postoperative lactate levels, continuous renal replacement therapy (CRRT), and mechanical ventilation. Multivariate analysis revealed that in-hospital mortality rate increased with CRRT use and was lower in the closed ICU.
Conclusions Compared to an open ICU, a closed ICU was an independent factor in reducing in-hospital mortality through prompt and appropriate treatment.
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Background Early detection of critical events in hospitalized patients improves clinical outcomes and reduces mortality rates. Traditional early warning score systems, such as the National Early Warning Score 2 (NEWS2), effectively identify at-risk patients. Integrating artificial intelligence (AI) could enhance the predictive accuracy and operational efficiency of such systems. The study describes the development and implementation of an AI-enhanced early warning system based on a modified NEWS2 scale with laboratory parameters (mNEWS2-Lab) and evaluates its ability to improve patient safety in hospital wards.
Methods For this retrospective cohort study of 3,790 adults admitted to hospital wards, data were collected before and after implementing the mNEWS2-Lab protocol with and without AI enhancement. The study used a multivariate prediction model with statistical analyses such as Fisher's chi-square test, relative risk (RR), RR reduction, and various AI models (logistic regression, decision trees, neural networks). The economic cost of the intervention was also analyzed.
Results The mNEWS2-Lab reduced critical events from 6.15% to 2.15% (RR, 0.35; P<0.001), representing a 65% risk reduction. AI integration further reduced events to 1.59% (RR, 0.26; P<0.001) indicating a 10% additional risk reduction and enhancing early warning accuracy by 15%. The intervention was cost-effective, resulting in substantial savings by reducing critical events in hospitalized patients.
Conclusions The mNEWS2-Lab scale, particularly when integrated with AI models, is a powerful and cost-effective tool for the early detection and prevention of critical events in hospitalized patients.
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Background Carbon monoxide (CO) poisoning can lead to significant morbidity and mortality. However, relatively few studies have investigated its long-term mortality impact. This nationwide population-based cohort study examined the association between CO poisoning and long-term mortality.
Methods This retrospective study utilized data from the National Health Insurance Service database in South Korea. We compared the patients with CO poisoning to those without CO poisoning. Inverse probability treatment weights were applied to both groups to control for potential confounding factors. Subsequently, mortality was assessed using the incidence rate and Cox proportional hazard ratios.
Results This study included 23,387 patients with CO poisoning and 359,851 without it. Over a median follow-up period of 7.6 years after CO poisoning diagnosis, the mortality risk was 2.6 times higher in patients with CO poisoning compared to that in the control group. In a long-term follow-up of patients surviving beyond 30 days, mortality remained 2.18 times higher. Additionally, a higher mortality risk was observed in the relatively younger age group (18–39 years) and the group with fewer underlying diseases, as indicated by a Charlson Comorbidity Index score of 0.
Conclusions CO poisoning is associated with an elevated long-term mortality rate particularly in a relatively young and healthy population.
Background Delays in diagnosing sepsis in children afflicted with thermal injuries can result in high morbidity and mortality. Our study evaluated the role of the biomarkers Procalcitonin (PCT) and C-reactive protein (CRP) as predictors of early sepsis and mortality, respectively, in this group of patients.
Methods This was a prospective evaluation of 90 pediatric burn cases treated at a tertiary care burn center in Northern India. Patients, aged 1–16 years, presenting within 24 hours of being burned, with >10% body surface area of burn injury were included in the study. Levels of PCT and CRP were measured on days 1, 3, 5, and 7. Patients were followed until discharge, 30th post-burn day, or death, whichever occurred first.
Results Sepsis was clinically present in 49 of 90 (54.4%) cases with a median 30% total body surface area (TBSA) of burns. Mortality was seen in 31 of 90 (34.4%) cases with a median of 35% TBSA burns. High PCT and CRP were seen in the sepsis group, particularly on days 3, 5, and 7. PCT was also significantly higher in the mortality group (days 1 and 3).
Conclusions While PCT was a good early predictor of sepsis and mortality in children with burns, CRP was reliable as a predictor of sepsis only. Both markers, however, can serve as adjuncts to culture sensitivity reports for diagnosing early onset sepsis and initiation of antibiotic therapy in appropriate patients.
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Background Abnormal red blood cell distribution width (RDW) is associated with poor cardiovascular, respiratory, and coronavirus disease 2019 (COVID-19) outcomes. However, whether RDW provides prognostic insights regarding COVID-19 patients admitted to the intensive care unit (ICU) was unknown. Here, we retrospectively investigated the association of RDW with 30-day and 90- day mortalities, duration of mechanical ventilation, and length of ICU and hospital stay in patients with COVID-19.
Methods This study included 321 patients with COVID-19 aged >18 years who were admitted to the ICU between March 2020 and July 2022. The outcomes were mortality, duration of mechanical ventilation, and length of stay. RDW >14.5% was assessed in blood samples within 24 hours of admission.
Results The mortality rate was 30.5%. Multivariable Cox regression analysis showed an association between increased RDW and 30-day mortality (hazard ratio [HR], 3.64; 95% CI, 1.54–8.65), 90-day mortality (HR, 3.66; 95% CI, 1.59–8.40), and shorter duration of invasive ventilation (2.7 ventilator-free days, P=0.033).
Conclusions Increased RDW in COVID-19 patients at ICU admission was associated with increased 30-day and 90-day mortalities, and shorter duration of invasive ventilation. Thus, RDW can be used as a surrogate biomarker for clinical outcomes in COVID-19 patients admitted to the ICU.
Background Age is a significant consideration for intensive care unit (ICU) admission. However, the reported associations between increasing age and mortality vary across studies, and data in the local context of Malaysia are lacking. The objective of the present study was to determine the impact of increasing age on ICU mortality.
Methods A retrospective cohort study of ICU patients was conducted between January 2020 and November 2023 at a university hospital in Malaysia. Patients were classified into two categories according to age (years) and into four groups according to National Library of Medicine Medical Subject Headings (MeSH): young adult (19–24), adult (25–44), middle age (45–64), and elderly (≥65). The Cochran-Armitage test for trend and Cox proportional hazards regression analyses were performed to evaluate the impact of increasing age on ICU mortality.
Results A total of 1,661 patients was analyzed. The Cochran-Armitage test showed a significant positive association between ICU mortality rate and age group (Z=−4.86, P<0.01) or MeSH category (Z=−5.36, P<0.01). After adjusting for other confounders, the strongest predictor for ICU mortality in the Cox proportional hazards regression analyses was age, with the elderly age group having the highest adjusted hazard ratio of 4.777 (95% CI, 1.128–20.231; P=0.03).
Conclusions Age had a significant impact on ICU mortality in our cohort of critically ill patients.
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Background Hypothermia is a relatively common complication in patients receiving continuous renal replacement therapy (CRRT). However, few studies have reported the factors associated with hypothermia.
Methods A retrospective cohort study was performed in five intensive care units (ICUs) to evaluate the incidence of hypothermia and the predictive factors for developing hypothermia during CRRT, with hypothermia defined as a time-weighted average temperature <36 °C.
Results From January 2020 to December 2021, 300 patients were enrolled. Hypothermia developed in 23.7% of them within the first 24 hours after CRRT initiation. Compared to non-hypothermic patients, hypothermic patients were older and had lower body weight, more frequent acidemia, and higher ICU and 30-day mortality rates. In the multivariate analysis, age >70 years (odds ratio [OR], 2.59; 95% CI, 1.38–4.98; P=0.004), higher positive fluid balance on the day before CRRT (OR, 1.11; 95% CI, 1.02–1.22; P=0.02), and CRRT dose (OR, 1.003; 95% CI, 1.00–1.01; P=0.04) were significantly associated with hypothermia. Conversely, a higher body weight was independently associated with mitigated risk of hypothermia (OR, 0.89; 95% CI, 0.81–0.97; P=0.01). Moreover, a higher coefficient of variance of temperature was associated with greater ICU mortality (OR, 1.41; 95% CI, 1.13–1.78; P=0.003).
Conclusions Hypothermia during CRRT is a relatively common occurrence, and factors associated with hypothermia onset in the first 24 hours include older age, lower body weight, higher positive fluid balance on the day before CRRT, and higher CRRT dose. Greater temperature variability was associated with increased ICU mortality.
Seungjoo Lee, Moinay Kim, Min-Yong Kwon, Sae Min Kwon, Young San Ko, Yeongu Chung, Wonhyoung Park, Jung Cheol Park, Jae Sung Ahn, Hanwool Jeon, Jihyun Im, Jae Hyun Kim
Acute Crit Care. 2024;39(2):282-293. Published online May 30, 2024
Background This study evaluates the effectiveness of Therapeutic Hypothermia (TH) in treating poor-grade aneurysmal subarachnoid hemorrhage (SAH), focusing on functional outcomes, mortality, and complications such as vasospasm, delayed cerebral ischemia (DCI), and hydrocephalus.
Methods Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a comprehensive literature search was conducted across multiple databases, including Medline, Embase, and Cochrane Central, up to November 2023. Nine studies involving 368 patients were selected based on eligibility criteria focusing on TH in poor-grade SAH patients. Data extraction, bias assessment, and evidence certainty were systematically performed.
Results The primary analysis of unfavorable outcomes in 271 participants showed no significant difference between the TH and standard care groups (risk ratio [RR], 0.87). However, a significant reduction in vasospasm was observed in the TH group (RR, 0.63) among 174 participants. No significant differences were found in DCI, hydrocephalus, and mortality rates in the respective participant groups.
Conclusions TH did not significantly improve primary unfavorable outcomes in poor-grade SAH patients. However, the reduction in vasospasm rates indicates potential specific benefits. The absence of significant findings in other secondary outcomes and mortality highlights the need for further research to better understand TH's role in treating this patient population.
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Background Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown to reduce organ dysfunction in renal and cardiovascular disease. There are limited data on the role of SGLT2i in acute organ dysfunction. We conducted a study to assess the effect of SGLT2i taken prior to intensive care unit (ICU) admission in diabetic patients admitted with septic shock.
Methods This retrospective cohort study used electronic medical records and included diabetic patients admitted to the ICU with septic shock. We compared diabetic patients on SGLT2i to those who were not on SGLT2i prior to admission. The primary outcome was in-hospital mortality, and secondary outcomes included hospital and ICU length of stay, use of renal replacement therapy, and 28- and 90-day mortality.
Results A total of 98 diabetic patients was included in the study, 36 in the SGLT2i group and 62 in the non-SGLT2i group. The Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation III scores were similar in the groups. Inpatient mortality was significantly lower in the SGLT2i group (5.6% vs. 27.4%, P=0.008). There was no significant difference in secondary outcomes.
Conclusions Our study found that diabetic patients on SGLT2i prior to hospitalization who were admitted to the ICU with septic shock had lower inpatient mortality compared to patients not on SGLT2i.
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Background The Controlling Nutritional Status (CONUT) score and the prognostic nutritional index (PNI) have emerged as important nutritional indices because they provide an objective assessment based on data. We aimed to investigate how these nutritional indices relate to outcomes in patients with sepsis.
Methods Data were collected retrospectively at five hospitals for patients aged ≥18 years receiving treatment for sepsis between January 1, 2017, and December 31, 2021. Serum albumin and total cholesterol concentrations, and peripheral lymphocytes were used to calculate the CONUT score and PNI. To identify predictors correlated with 30-day mortality, analyses were conducted using univariate and multivariate Cox proportional hazards models.
Results The 30-day mortality rate among 9,763 patients was 15.8% (n=1,546). The median CONUT score was 5 (interquartile range [IQR], 3–7) and the median PNI score was 39.6 (IQR, 33.846.4). Higher 30-day mortality rates were associated with individuals with moderate (CONUT score: 5–8; PNI: 35–38) or severe (CONUT: 9–12; PNI: <35) malnutrition compared with those with no malnutrition (CONUT: 0–1; PNI: >38). With CONUT scores, the hazard ratio (HR) associated with moderate malnutrition was 1.52 (95% confidence interval [CI], 1.24–1.87; P<0.001); for severe, HR=2.42 (95% CI, 1.95–3.02; P<0.001). With PNI scores, the HR for moderate malnutrition was 1.29 (95% CI, 1.09–1.53; P=0.003); for severe, HR=1.88 (95% CI, 1.67–2.12; P<0.001).
Conclusions The nutritional indices CONUT score and PNI showed significant associations with mortality of sepsis patients within 30 days.
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Background Identifying critically ill patients at risk of cardiac arrest is important because it offers the opportunity for early intervention and increased survival. The aim of this study was to develop a deep learning model to predict critical events, such as cardiopulmonary resuscitation or mortality.
Methods This retrospective observational study was conducted at a tertiary university hospital. All patients younger than 18 years who were admitted to the pediatric intensive care unit from January 2010 to May 2023 were included. The main outcome was prediction performance of the deep learning model at forecasting critical events. Long short-term memory was used as a deep learning algorithm. The five-fold cross validation method was employed for model learning and testing.
Results Among the vital sign measurements collected during the study period, 11,660 measurements were used to develop the model after preprocessing; 1,060 of these data points were measurements that corresponded to critical events. The prediction performance of the model was the area under the receiver operating characteristic curve (95% confidence interval) of 0.988 (0.9751.000), and the area under the precision-recall curve was 0.862 (0.700–1.000).
Conclusions The performance of the developed model at predicting critical events was excellent. However, follow-up research is needed for external validation.
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Background Platelet-to-Lymphocyte ratio (PLR) has been studied as a prognostic factor for various diseases and traumas. This study examined the utility of PLR as a tool for predicting 30-day mortality in patients experiencing severe trauma.
Methods This study included 139 patients who experienced trauma and fulfilled ≥1 criteria for activation of the hospital’s severe trauma team. Patients were divided into non-survivor and survivor groups. Mean PLR values were compared between the groups, the optimal PLR cut-off value was determined, and mortality and survival analyses were performed. Statistical analyses were performed using SPSS ver. 26.0. The threshold of statistical significance was P<0.05.
Results There was a significant difference in mean (±standard deviation) PLR between the non-survivor (n=36) and survivor (n=103) groups (53.4±30.1 vs. 89.9±53.3, respectively; P<0.001). Receiver operating characteristic (ROC) curve analysis revealed an optimal PLR cut-off of 65.35 (sensitivity, 0.621; specificity, 0.694, respectively; area under the ROC curve, 0.742), and Kaplan-Meier survival analysis revealed a significant difference in mortality rate between the two groups.
Conclusions PLR can be calculated quickly and easily from a routine complete blood count, which is often performed in the emergency department for individuals who experience trauma. The PLR is useful for predicting 30-day mortality in trauma patients with severe trauma team activation.
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Background Pneumonia frequently leads to intensive care unit (ICU) admission and is associated with a high mortality risk. This study aimed to assess the impact of early bronchoscopy administered within 3 days of ICU admission on mortality in patients with pneumonia using the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database.
Methods A single-center retrospective analysis was conducted using the MIMIC-IV data from 2008 to 2019. Adult ICU-admitted patients diagnosed with pneumonia were included in this study. The patients were stratified into two cohorts based on whether they underwent early bronchoscopy. The primary outcome was the 28-day mortality rate. Propensity score matching was used to balance confounding variables.
Results In total, 8,916 patients with pneumonia were included in the analysis. Among them, 783 patients underwent early bronchoscopy within 3 days of ICU admission, whereas 8,133 patients did not undergo early bronchoscopy. The primary outcome of the 28-day mortality between two groups had no significant difference even after propensity matched cohorts (22.7% vs. 24.0%, P=0.589). Patients undergoing early bronchoscopy had prolonged ICU (P<0.001) and hospital stays (P<0.001) and were less likely to be discharged to home (P<0.001).
Conclusions Early bronchoscopy in severe pneumonia patients in the ICU did not reduce mortality but was associated with longer hospital stays, suggesting it was used in more severe cases. Therefore, when considering bronchoscopy for these patients, it's important to tailor the decision to each individual case, thoughtfully balancing the possible advantages with the related risks.
Jae Kyeom Sim, Sang-Min Lee, Hyung Koo Kang, Kyung Chan Kim, Young Sam Kim, Yun Seong Kim, Won-Yeon Lee, Sunghoon Park, So Young Park, Ju-Hee Park, Yun Su Sim, Kwangha Lee, Yeon Joo Lee, Jin Hwa Lee, Heung Bum Lee, Chae-Man Lim, Won-Il Choi, Ji Young Hong, Won Jun Song, Gee Young Suh
Acute Crit Care. 2024;39(1):91-99. Published online January 26, 2024
Background Mechanical power (MP) has been reported to be associated with clinical outcomes. Because the original MP equation is derived from paralyzed patients under volume-controlled ventilation, its application in practice could be limited in patients receiving pressure-controlled ventilation (PCV). Recently, a simplified equation for patients under PCV was developed. We investigated the association between MP and intensive care unit (ICU) mortality.
Methods We conducted a retrospective analysis of Korean data from the Fourth International Study of Mechanical Ventilation. We extracted data of patients under PCV on day 1 and calculated MP using the following simplified equation: MPPCV = 0.098 ∙ respiratory rate ∙ tidal volume ∙ (ΔPinsp + positive end-expiratory pressure), where ΔPinsp is the change in airway pressure during inspiration. Patients were divided into survivors and non-survivors and then compared. Multivariable logistic regression was performed to determine association between MPPCV and ICU mortality. The interaction of MPPCV and use of neuromuscular blocking agent (NMBA) was also analyzed.
Results A total of 125 patients was eligible for final analysis, of whom 38 died in the ICU. MPPCV was higher in non-survivors (17.6 vs. 26.3 J/min, P<0.001). In logistic regression analysis, only MPPCV was significantly associated with ICU mortality (odds ratio, 1.090; 95% confidence interval, 1.029–1.155; P=0.003). There was no significant effect of the interaction between MPPCV and use of NMBA on ICU mortality (P=0.579).
Conclusions MPPCV is associated with ICU mortality in patients mechanically ventilated with PCV mode, regardless of NMBA use.
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The primary aim of this review is to explore current knowledge on the relationship between institutional intensive care unit (ICU) patient volume and patient outcomes. Studies indicate that a higher institutional ICU patient volume is positively correlated with patient survival. Although the exact mechanism underlying this association remains unclear, several studies have proposed that the cumulative experience of physicians and selective referral between institutions may play a role. The overall ICU mortality rate in Korea is relatively high compared to other developed countries. A distinctive aspect of critical care in Korea is the existence of significant disparities in the quality of care and services provided across regions and hospitals. Addressing these disparities and optimizing the management of critically ill patients necessitates thoroughly trained intensivists who are well-versed in the latest clinical practice guidelines. A fully functioning unit with adequate patient throughput is also essential for maintaining consistent and reliable quality of patient care. However, the positive impact of ICU volume on mortality outcomes is also linked to complex organizational factors, such as multidisciplinary rounds, nurse staffing and education, the presence of a clinical pharmacist, care protocols for weaning and sedation, and a culture of teamwork and communication. Despite some inconsistencies in the association between ICU patient volume and patient outcomes, which are thought to arise from differences in healthcare systems, ICU case volume significantly affects patient outcomes and should be taken into account when formulating related healthcare policies.
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Background Deaths can occur after a patient has survived treatment for a serious illness in an intensive care unit (ICU). Mortality rates after leaving the ICU can be considered indicators of health care quality. This study aims to describe risk factors and mortality of surviving patients discharged from an ICU in a university hospital.
Methods Retrospective cohort study carried out from January 2017 to December 2018. Data on age, sex, length of hospital stay, diagnosis on admission to the ICU, hospital discharge outcome, presence of infection, and Simplified Acute Physiology Score (SAPS) III prognostic score were collected. Infected patients were considered as those being treated for an infection on discharge from the ICU. Patients were divided into survivors and non-survivors on leaving the hospital. The association between the studied variables was performed using the logistic regression model.
Results A total of 1,025 patients who survived hospitalization in the ICU were analyzed, of which 212 (20.7%) died after leaving the ICU. When separating the groups of survivors and non-survivors according to hospital outcome, the median age was higher among non-survivors. Longer hospital stays and higher SAPS III values were observed among non-survivors. In the logistic regression, the variables age, length of hospital stay, SAPS III, presence of infection, and readmission to the ICU were associated with hospital mortality.
Conclusions Infection on ICU discharge, ICU readmission, age, length of hospital stay, and SAPS III increased risk of death in ICU survivors.
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Background In patients with severe trauma, the diagnosis of acute kidney injury (AKI) is important because it is a predictive factor for poor prognosis and can affect patient care. The diagnosis and staging of AKI are based on change in serum creatinine (SCr) levels from baseline. However, baseline creatinine levels in patients with traumatic injuries are often unknown, making the diagnosis of AKI in trauma patients difficult. This study aimed to enhance the accuracy of AKI diagnosis in trauma patients by presenting an appropriate reference creatinine estimate (RCE).
Methods We reviewed adult patients with severe trauma requiring intensive care unit admission between 2015 and 2019 (n=3,228) at a single regional trauma center in South Korea. AKI was diagnosed based on the current guideline published by the Kidney Disease: Improving Global Outcomes organization. AKI was determined using the following RCEs: estimated SCr75-modification of diet in renal disease (MDRD), trauma MDRD (TMDRD), admission creatinine level, and first-day creatinine nadir. We assessed inclusivity, prognostic ability, and incrementality using the different RCEs.
Results The incidence of AKI varied from 15% to 46% according to the RCE used. The receiver operating characteristic curve of TMDRD used to predict mortality and the need for renal replacement therapy (RRT) had the highest value and was statistically significant (0.797, P<0.001; 0.890, P=0.002, respectively). In addition, the use of TMDRD resulted in a mortality prognostic ability and the need for RRT was incremental with AKI stage.
Conclusions In this study, TMDRD was feasible as a RCE, resulting in optimal post-traumatic AKI diagnosis and prognosis.
Background The study aimed to describe the clinical course, outcomes, and prognostic factors of chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure.
Methods This retrospective study involved patients with acute hypercapnic respiratory failure due to COPD of any cause admitted to the intensive care unit (ICU) for non-invasive or invasive mechanical ventilation (IMV) support between December 2015 and February 2020.
Results One hundred patients were evaluated. The main causes of acute hypercapnic respiratory failure were bronchitis, pneumonia, and heart failure. The patients’ mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 23.0±7.2, and their IMV rate was 43%. ICU, in-hospital, and 90-day mortality rates were 21%, 29%, and 39%, respectively. Non-survivors had more pneumonia, shock within the first 24 hours of admission, IMV, vasopressor use, and renal replacement therapy, along with higher APACHE II scores, lower admission albumin levels and PaO2/ FiO2 ratios, and longer ICU and hospital stays than survivors. Logistic regression analysis identified APACHE II score (odds ratio [OR], 1.157; 95% confidence interval [CI], 1.017–1.317; P=0.026), admission PaO2/FiO2 ratio (OR, 0.989; 95% CI, 0.978–0.999; P=0.046), and vasopressor use (OR, 8.827; 95% CI, 1.650–47.215; P=0.011) as predictors of ICU mortality. APACHE II score (OR, 1.099; 95% CI, 1.021–1.182; P=0.011) and admission albumin level (OR, 0.169; 95% CI, 0.056–0.514; P=0.002) emerged as predictors of 90-day mortality.
Conclusions APACHE II scores, the PaO2/FiO2 ratio, vasopressor use, and albumin levels are significant short-term mortality predictors in severely ill COPD patients with acute hypercapnic respiratory failure.
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