Hemophagocytic Lymphohistiocytosis: Potentially Underdiagnosed in Intensive Care Units

This article by Lachmann et al was published in Shock in August 2018.
Background:  Hemophagocytic lymphohistiocytosis in adults (aHLH) is a rare life-threatening hyperinflammatory syndrome caused by excessive activation of macrophages and CD8+ T-cells. Due to the clinical overlap with severe sepsis, aHLH often remains undiagnosed resulting in poor outcome. Here, we present a retrospective study of incidence, clinical findings, and the outcome of aHLH in intensive care units (ICUs).
Methods:  This retrospective analysis was performed at the university hospital Charité – Universitätsmedizin Berlin. We gathered data from 556 out of 46,532 patients admitted to our anesthesiological ICUs between 2006 and 2013, who had at least one plasma ferritin measurement during ICU treatment, and were at least 18 years old. Of these, 244 patients with ferritin at least 500 μg/L and available datasets of at least 4 HLH-2004 criteria were included. HLH-2004 diagnostic criteria and the recently published HScore were used. An aHLH expert team retrospectively reviewed the potential aHLH cases.
Results:  Seventy-one of the included 244 patients died; 9 out of the 244 patients were retrospectively classified as aHLH of whom 4 patients had died (44.4%). Two of the 9 aHLH patients had been correctly diagnosed and had received specific aHLH treatment. Thus, 7 out of 9 patients (77.8%) remained undetected. ICU patients with at least 1 captured ferritin value and hyperferritinemia showed an aHLH rate of 3.7%, which rises up to 5.6% when only deceased patients are considered. Mortality in this selected cohort is 44.4%.
Conclusions:  Overall, 7 out of 9 patients (77.8%) suffering from aHLH remained undiagnosed. Awareness of this life-threatening syndrome, especially in ICUs, should be raised. The inclusion of ferritin into the admission lab panel for ICU is warranted.
The full text of this article is freely available via this link.


Stool cultures at the ICU: get rid of it!

This research by Manthey and colleagues was published in Annals of Intensive Care January 2018 issue.

Background:  Stool cultures for Campylobacter, Salmonella and Shigella and/or Yersinia spp. are frequently ordered in critically ill patients with diarrhea. The aim of this study is to analyze the diagnostic yield in a large cohort of critically ill patients. Therefore, we performed a cohort study at the Department of Intensive Care Medicine of a University Hospital (11 ICUs).

Results:  From all patients who were admitted to the ICU between 2010 and 2015, stool cultures were taken from 2.189/36.477 (6%) patients due to diarrhea. Results of all stool cultures tested for Campylobacter, Salmonella and Shigella and/or Yersinia spp. were analyzed. Overall, 5.747 tests were performed; only six were positive (0.1%). In four of these, Campylobacter spp. were detected; diarrhea started within 48 h after ICU admission. Two patients with Salmonella spp. detection were chronic shedders. On the contrary, testing for Clostridium difficile via GDH- and toxin A/B-EIA yielded positive results in 179/2209 (8.1%) tests and revealed 144/2.189 (6.6%) patients with clinically relevant C. difficile infection.

Conclusions:  Stool testing for enteric pathogens other than C. difficile should be avoided in ICU patients and is only reasonable when diarrhea commenced less than 48 h after hospital admission.

The full text of the article is available via this link.

Innovative haematological parameters for early diagnosis of sepsis in adult patients admitted in intensive care unit

This article by Buoro et al was published in the August issue of “Journal of Clinical Pathology”.

Aims:  This study was aimed to investigate the role of erythrocyte, platelet and reticulocyte (RET) parameters, measured by new haematological analyser Sysmex XN and C reactive protein (CRP), for early diagnosis of sepsis during intensive care unit (ICU) stay.

Methods:  The study population consisted of 62 ICU patients, 21 of whom developed sepsis during ICU stay and 41 who did not. The performance for early diagnosing of sepsis was calculated as area under the curve (AUC) of receiver operating characteristics curves analysis.

Results:  Compared with CRP (AUC 0.81), immature platelet fraction (IPF) (AUC 0.82) showed comparable efficiency for identifying the onset of sepsis. The association with the risk of developing sepsis during ICU stay was also assessed. One day before the onset of sepsis, a decreased of RET% was significantly associated with the risk of developing sepsis (OR=0.35, 95% CI 0.14 to 0.87), whereas an increase of IPF absolute value (IPF#) was significantly associated with the risk of developing sepsis (OR=1.13, 95% CI 1.03 to 1.24) 2 days before the onset of sepsis. The value of CRP was not predictive of sepsis at either time points.

Conclusions:  IPF# and RET% may provide valuable clinical information for predicting the risk of developing sepsis, thus allowing early management of patients before the onset of clinically evident systemic infections.


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Understanding Negative Predictive Value of Diagnostic Tests Used in Clinical Practice

Umburger, R.A. et al. (2017) Dimensions of Critical Care Nursing36(1) pp. 22–29


Nurses review, evaluate, and use diagnostic test results on a routine basis. However, the skills necessary to evaluate a particular test using statistical outcome measures is often lacking. The purpose of this article is to examine and interpret the underlying principles for use of the statistical outcomes of diagnostic screening tests (sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values, with a discussion about use of SpPIn [Specificity, Positive test = rule in], and SnNOut [Sensitivity, Negative test = rule out]) in advanced nursing clinical practice.

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Multiple organ dysfunction syndrome in critically ill children: clinical value of two lists of diagnostic criteria

Villeneuve, A. et al. Annals of Intensive Care2016. 6:40.

Background: Two sets of diagnostic criteria of paediatric multiple organ dysfunction syndrome (MODS) were published by Proulx in 1996 and by Goldstein in 2005. We hypothesized that this changes the epidemiology of MODS. Thus, we determined the epidemiology of MODS, according to these two sets of diagnostic criteria, we studied the intra- and inter-observer reproducibility of each set of diagnostic criteria, and we compared the association between cases of MODS at paediatric intensive care unit (PICU) entry, as diagnosed by each set of diagnostic criteria, and 90-day all-cause mortality.

Methods: All consecutive patients admitted to the tertiary care PICU of Sainte-Justine Hospital, from April 21, 2009 to April 20, 2010, were considered eligible for enrolment into this prospective observational cohort study. The exclusion criteria were gestational age < 40 weeks, age < 3 days or > 18 years at PICU entry, pregnancy, admission immediately after delivery. No patients were censored. Daily monitoring using medical chart ended when the patient died or was discharged from PICU. Mortality was monitored up to death, hospital discharge, or 90 days post PICU entry, whatever happened first. Concordance rate and kappa score were calculated to assess reproducibility. The number of MODS identified with Proulx and Goldstein definitions was compared using 2-by-2 contingency tables. Student’s t test or Wilcoxon signed-ranked test was used to compare continuous variables with normal or abnormal distribution, respectively. We performed a Kaplan–Meier survival analysis to assess the association between MODS at PICU entry and 90-day mortality.

Results: The occurrence of MODS was monitored daily and prospectively in 842 consecutive patients admitted to the PICU of Sainte-Justine Hospital over 1 year. According to Proulx and Goldstein diagnostic criteria, 180 (21.4 %) and 314 patients (37.3 %) had MODS over PICU stay, respectively. Concordance of MODS diagnosis over PICU stay was 81.3 % (95 % CI 78.6–83.9 %), and kappa score was 0.56 (95 % CI 0.50–0.61). Discordance was mainly attributable to cardiovascular or neurological dysfunction criteria. The proportion of patients with MODS at PICU entry who died within 90 days was higher with MODS diagnosed with Proulx criteria (17.8 vs. 11.5 %, p = 0.038), as well as the likelihood ratio of death (4.84 vs. 2.37). On the other hand, 90-day survival rate of patients without MODS at PICU entry was similar (98.6 vs. 98.9 % (p = 0.73).

Conclusions: Proulx and Goldstein diagnostic criteria of paediatric MODS are not equivalent. The epidemiology of paediatric MODS varies depending on which set of diagnostic criteria is applied.

Read the full article here