Background Critically ill septic children are susceptible to electrolyte abnormalities, including magnesium disturbance, that can easily be neglected. This study examined the potential correlation between serum magnesium levels upon admission to the pediatric intensive care unit (PICU) and the outcomes of critically ill septic patients.
Methods This prospective study, conducted from May 2023 to November 2023, included 76 children with sepsis who underwent clinical and lab assessments that included initial magnesium levels. The outcome of sepsis was documented. Predictors of mortality were identified through multivariate logistic regression models, with discrimination and calibration assessed using the area under the curve (AUC).
Results The median magnesium level upon PICU admission was 2.0 mg/dl (range 1.1–4.9), and it was slightly higher in non-survivors than survivors (2.1 mg/dl; interquartile range [IQR], 1.9–2.5 vs. 2.0; IQR, 1.8–2.6, respectively), Hypermagnesemia was observed to have a negative effect on critically ill septic patients. It was also found that hypermagnesemia was associated with low C-reactive protein levels (P=0.043). With a cut-off of 5.5, the pediatric Sequential Organ Failure Assessment score strongly predicted mortality (AUC=0.717, P<0.001), with a sensitivity of 64.3% and specificity of 68.8%.
Conclusion As an initial predictor of mortality, the serum magnesium level cannot be used alone; however, hypermagnesemia has a negative impact on critically ill septic patients. Thus, healthcare professionals should be cautious with magnesium administration.
Tae Jung Kim, Hyun Joo Lee, Samina Park, Sang-Bae Ko, Soo-Hyun Park, Seung Hwan Yoon, Kwon Joong Na, In Kyu Park, Chang Hyun Kang, Young Tae Kim, Sun Mi Choi, Jimyung Park, Joong-Yub Kim, Hong Yeul Lee
Received September 5, 2024 Accepted November 14, 2024 Published online January 7, 2025
Background Posterior reversible encephalopathy syndrome (PRES) is a rare complication of lung transplantation with poorly understood risk factors and clinical characteristics. This study aimed to examine the occurrence, risk factors, and clinical data of patients who developed PRES following lung transplantation.
Methods A retrospective analysis was conducted on 147 patients who underwent lung transplantation between February 2013 and December 2023. The patients were diagnosed with PRES based on the clinical symptoms and radiological findings. We compared the baseline characteristics and clinical information, including primary lung diseases and immunosuppressive therapy related to lung transplantation operations, between the PRES and non-PRES groups.
Results PRES manifested in 7.5% (n=11) of the patients who underwent lung transplantation, with a median onset of 15 days after operation. Seizures were identified as the predominant clinical manifestation (81.8%, n=9) in the group diagnosed with PRES. All patients diagnosed with PRES recovered fully. Patients with PRES were significantly associated with connective tissue disease-associated interstitial lung disease (45.5% vs. 18.4%, P=0.019, odds ratio=9.808; 95% CI, 1.064–90.386, P=0.044). Nonetheless, no significant variance was observed in the type of immunotherapy, such as the use of calcineurin inhibitors, blood pressure, or acute renal failure subsequent to lung transplantation.
Conclusions PRES typically manifests shortly after lung transplantation, with seizures being the predominant initial symptom. The presence of preexisting connective tissue disease as the primary lung disease represents a significant risk factor for PRES following lung transplantation.
Background Good sepsis management is key to successful sepsis therapy and optimal patient outcomes. Objectives: This study aimed to determine obstacles among nurses and doctors to implementing the hour-1 sepsis bundle in a secondary hospital in Indonesia.
Methods This was a qualitative study with a phenomenological approach. Data were obtained from one-on-one in-depth interviews with 13 doctors and nurses in the intensive care unit and emergency department who were purposively sampled. Data were analyzed using content analysis.
Results Five main themes were revealed in the analysis: incomplete implementation of the hour-1 sepsis bundle, lack of knowledge about the hour-1 sepsis bundle, cost issues, lack of supporting facilities, and lack of coordination among health workers.
Conclusions Optimizing regional health laboratories, optimizing the use of quick Sequential Organ Failure Assessment (qSOFA) and SOFA, and creating a series of sepsis protocols within the hospital are some solutions that secondary hospitals can implement to ensure appropriate management of sepsis cases. Involvement of health policyholders and hospital management is needed to address these challenges.
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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The efficacy of intensivist-led closed-system intensive care units in improving outcomes for cancer patients requiring emergent surgical intervention Eun Young Kim Acute and Critical Care.2024; 39(4): 640. CrossRef
Background This meta-analysis was conducted to evaluate the impact of high-intensity statin
treatment on new-onset postoperative atrial fibrillation (POAF) after coronary artery bypass grafting
(CABG).
Methods Four databases were searched for studies that enrolled patients who underwent CABG
and investigated the impact of perioperative use of high-intensity statins on the occurrence rate
of POAF. The primary outcome was the incidence of POAF. Secondary outcomes were operative
mortality and perioperative myocardial infarction (PMI). Publication bias was assessed using a funnel
plot and Egger’s test.
Results Nine articles (eight randomized controlled trials and one non-randomized study: n=3,072)
were selected. Rosuvastatin (20 mg) was used in four studies, while atorvastatin (40–80 mg) was
used in the other five studies. Reported incidences of POAF in the included studies ranged from
11% to 48.8%. Pooled analyses showed that the incidence of POAF was significantly lower in patients
treated with high-intensity statins than in patients in the control group patients (odds ratio,
0.43; 95% CI, 0.27–0.68; P<0.001). Subgroup analyses showed that the impact of high-intensity
statins was significant in studies using atorvastatin but not in studies using rosuvastatin. There
was no significant subgroup difference in the primary endpoint between studies using a placebo
and those using low-dose statins. Secondary outcomes, including operative mortality and the incidence
of PMI, were not affected by high-intensity statin treatment.
Conclusions Perioperative use of high-intensity statins is associated with a 57% reduction in the
occurrence of POAF among patients undergoing CABG.
Background Despite the high mortality associated with bloodstream infection (BSI), early detection of this condition is challenging in critical settings. The objective of this study was to create a machine learning tool for rapid recognition of BSI in critically ill children.
Methods Data were extracted from a derivative cohort comprising patients who underwent at least one blood culture during hospitalization in the pediatric intensive care unit (PICU) of a tertiary hospital from January 2020 to June 2023 for model development. Data from another tertiary hospital were utilized for external validation. Variables selected for model development were age, white blood cell count with segmented neutrophil count, C-reactive protein, bilirubin, liver enzymes, glucose, body temperature, heart rate, and respiratory rate. Algorithms compared were extra trees, random forest, light gradient boosting, extreme gradient boosting, and CatBoost.
Results We gathered 1,806 measurements and recorded 290 hospitalizations from 263 patients in the derivative cohort. Median age on admission was 43 months, with an interquartile range of 10–118.75 months, and a male predominance was observed (n=160, 55.2%). Candida albicans was the most prevalent pathogen, and median duration to confirm BSI was 3 days (range, 3–4). Patients with BSI experienced significantly higher in-hospital mortality and prolonged stays in the PICU than patients without BSI. Random forest classifier achieved the highest area under the receiver operating characteristic curve of 0.874 (0.762 for the validation set).
Conclusions We developed a machine learning model that predicts BSI with acceptable performance. Further research is necessary to validate its effectiveness.
Background Hypoglycemia is a serious, often overlooked complication of treating hyperkalemia with insulin and dextrose. If not recognized and managed, it can increase morbidity and mortality. This study aimed to estimate the incidence of hypoglycemia in hyperkalemic patients treated with 10 units of intravenous insulin, 50 ml of 50% dextrose, 10 ml of 10% calcium gluconate, and salbutamol nebulization. Additionally, the timing of hypoglycemia onset and its associated factors were studied.
Methods This prospective observational study included hyperkalemic patients (serum potassium >5.5 mmol/L) who visited the emergency department between January 26, 2020, and August 26, 2021. The primary outcome was hypoglycemia (blood glucose <70 mg/dl) within 3 hours of receiving the standard treatment. Glucose levels were measured hourly for 3 hours. Univariate and multivariate logistic regression identified factors associated with hypoglycemia.
Results Of 100 patients, 69% were male, and the median age was 46 years (IQR, 30–60 years). Hypoglycemia occurred in 44%, and 10% developed severe hypoglycemia (blood glucose <54 mg/dl). The median time for hypoglycemia onset was 2 hours (IQR, 1–2 hours). Low pretreatment blood glucose (<100 mg/dl) was significantly associated with hypoglycemia, according to both univariate and multivariate analyses.
Conclusions The study found a higher incidence of hypoglycemia in hyperkalemia treatment than reported in retrospective studies, suggesting the need for standardized management protocols with integrated glucose monitoring.
Background In trauma patients, unplanned intensive care unit (ICU) readmission (UIR) is associated with poor clinical outcomes. In this study, we aimed to analyze associated factors for UIR in trauma patients.
Methods This retrospective study was conducted on trauma patients admitted to the ICU at a trauma center from January 2016 to December 2022. Clinical information at admission, the first ICU hospitalization, first discharge from the ICU, and reasons for readmission were collected. Patients who were successfully discharge from the ICU were compared to UIR patients. Logistic regression was performed to determine the factors with a significant impact on ICU readmission.
Results Here, 5,529 patients were admitted to the ICU over 7 years, and 212 patients (3.8%) experienced UIR. Among patients who experienced UIR, 9 (4.2%) died. In the UIR patients, hospital stay (20 days [interquartile range, 13–35] vs. 45 days [28–67], P<0.001), total ICU stay (5 days [3– 11] vs. 17 days [9–35], P<0.001), and complications during the first ICU hospitalization were significantly higher. The most common reason for UIR was respiratory problem (53.8%). In multivariable analysis, cervical spine operation during the first ICU hospitalization (odds ratio, 6.56; 95% CI, 3.62–11.91; P<0.001), renal replacement therapy (RRT; 3.52, 2.06–5.99, P<0.001), and massive blood transfusion protocol (MTP; 1.74, 1.08–2.81, P=0.023) were most highly related with UIR.
Conclusions Because UIR patients had poor outcomes, trauma patients who underwent cervical spine operation, RRT, or MTP require monitoring in the general ward, especially for respiratory problems.
Background Abnormal pupillary reactivity is a neurological emergency requiring prompt evaluation to identify its underlying causes. Although isolated unilateral mydriasis without accompanying neurological abnormalities is rare, it has occasionally been associated with nebulizer use. We aimed to quantitatively assess pupillary changes using a pupillometer in cases of isolated mydriasis, which has not been described in previous studies.
Methods We retrospectively analyzed patients who developed unilateral mydriasis after using an ipratropium bromide nebulizer using a prospectively collected database in the intensive care unit (ICU) between April 2019 and August 2020. An automated pupillometer (NPi-100 or NPi-200) was used for quantitative pupillary assessment. The Neurological Pupil index (NPi) value at the time of unilateral mydriasis was assessed, and the latency before and after the application of the ipratropium bromide nebulizer was measured.
Results Five patients with isolated mydriasis were identified (mean age, 68 years; male, 60.0%), none of whom had neurological abnormalities other than pupillary light reflex abnormalities. A quantitative pupillometer examination revealed that the affected pupil was larger (5.67 mm vs. 3.20 mm) and had lower NPi values (0.60 vs. 3.40) than the unaffected side. These abnormalities resolved spontaneously without treatment (pupil size, 3.40 mm; NPi, 3.90). The affected pupil had a prolonged latency of 0.38 seconds (vs. 0.28 seconds), which improved to 0.30 seconds with the resolution of the anisocoria.
Conclusions In the ICU setting, it is important to keep in mind the ipratropium bromide nebulizer as the benign cause of unilateral mydriasis. Further, an automated pupilometer may be a useful tool for evaluating unilateral mydriasis.
Background Candidemia is associated with markedly high intensive care unit (ICU) mortality rates. Although the Impact of Early Enteral vs. Parenteral Nutrition on Mortality in Patients Requiring Mechanical Ventilation and Catecholamines (NUTRIREA-2) trial indicated that early enteral nutrition (EN) did not reduce 28-day mortality rates among critically ill patients with shock, the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend avoiding EN in cases of uncontrolled shock. Whether increased caloric intake from EN positively impacts clinical outcomes in patients with candidemia and shock remains unclear.
Methods We retrospectively collected data from a tertiary medical center between January 2015 and December 2018. We enrolled patients who developed shock within the first 7 days following ICU admission and received a diagnosis of candidemia during their ICU stay. Patients with an ICU stay shorter than 48 hours were excluded.
Results The study included 106 patients, among whom the hospital mortality rate was 77.4% (82 patients). The median age of the patients was 71 years, and the median Acute Physiology and Chronic Health Evaluation II score was 29. The Cox regression model revealed that a higher 7-day average caloric intake through EN (hazard ratio, 0.61; 95% CI, 0.44–0.83) was significantly associated with lower hospital mortality rates. Our findings suggest EN as the preferred feeding route for critically ill patients with shock.
Conclusions Increased caloric intake through EN may be associated with lower hospital mortality rates in patients with candidemia and shock.
Background Long-term survival data for critically ill children discharged to post-intensive care clinics are scarce, especially in Asia. The main objective of this study was to assess the prevalence of post–intensive-care morbidity among pediatric intensive care unit (PICU) survivors at 1 month and 1 year after hospital discharge and to identify the associated risk factors.
Methods We conducted a retrospective chart review of all children aged 1 month to 15 years who were admitted to the PICU for >48 hours from July 2019 to July 2022 and visited a post–intensive-care clinic 1 month and 1 year after hospital discharge. Post-intensive care morbidity was defined using the Pediatric Cerebral Performance Category (PCPC). Descriptive statistics, univariate, and multivariate analyses were conducted.
Results A total of 111 children visited the clinic at 1 month, and 100 of these children visited the clinic at 1 year. Only 39 of 111 children (35.2%) had normal PCPC assessments at 1 month, while 54 of 100 (54.0%) were normal at 1 year. Baseline developmental delays were significantly associated with any degree of disability and at least moderate disability at both time points. Mechanical ventilation for >7 days was associated with at least moderate disability at both time points, while PICU stay >7 days was significantly associated with moderate disability at 1 month and any degree of disability at 1 year.
Conclusions A substantial percentage of PICU survivors had persistent disabilities even 1 year after critical illness. A structured multidisciplinary post–intensive-care follow-up plan is warranted to provide optimal care for such children.
Chul Park, Nam Su Ku, Dae Won Park, Joo Hyun Park, Tae Sun Ha, Do Wan Kim, So Young Park, Youjin Chang, Kwang Wook Jo, Moon Seong Baek, Yijun Seo, Tae Gun Shin, Gina Yu, Jongmin Lee, Yong Jun Choi, Ji Young Jang, Yun Tae Jung, Inseok Jeong, Hwa Jin Cho, Ala Woo, Sua Kim, Dae-Hwan Bae, Sung Wook Kang, Sun Hyo Park, Gee Young Suh, Sunghoon Park
Acute Crit Care. 2024;39(4):445-472. Published online November 18, 2024
Background Despite recent advances and global improvements in sepsis recognition and supportive care, mortality rates remain high, and adherence to sepsis bundle components in Korea is low. To address this, the Korean Sepsis Alliance, affiliated with the Korean Society of Critical Care Medicine, developed the first sepsis treatment guidelines for Korea based on a comprehensive systematic review and meta-analysis.
Methods A de novo method was used to develop the guidelines. Methodologies included determining key questions, conducting a literature search and selection, assessing the risk of bias, synthesizing evidence, and developing recommendations. The certainty of evidence and the strength of recommendations were determined using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Draft recommendations underwent internal and external review processes and public hearings. The development of these guidelines was supported by a research grant from the Korean Disease Control and Prevention Agency.
Results In these guidelines, we focused on early treatments for adult patients with sepsis and septic shock. Through the guideline development process, 12 key questions and their respective recommendations were formulated. These include lactate measurement, fluid therapies, target blood pressure, antibiotic administration, use of vasopressors and dobutamine, extracorporeal membrane oxygenation, and echocardiography.
Conclusions These guidelines aim to support medical professionals in making appropriate decisions about treating adult sepsis and septic shock. We hope these guidelines will increase awareness of sepsis and reduce its mortality rate.