Time of admission to intensive care unit, strained capacity, and mortality: A retrospective cohort study

This research by Cardoso and colleagues was published online in June 2019 in the Journal of Critical Care.
Purpose:  We sought to study the association between afterhours ICU admission and ICU mortality considering measures of strained ICU capacity.
Materials and methods:  Retrospective analysis of 4141 admissions to 2 ICUs in Lisbon, Portugal (06/2016–06/2018). Primary exposure was ICU admission on 20:00 h–07:59 h. Primary outcome was ICU mortality. Measures of strained ICU capacity were: bed occupancy rate ≥ 90% and cluster of ICU admissions 2 h before or following index admission.
Results:  There were 1581 (38.2%) afterhours ICU admissions. Median APACHE II score (19 vs. 20) was similar between patients admitted afterhours and others (P = .27). Patients admitted afterhours had higher crude ICU mortality (15.4% vs. 21.9%; P < .001), but similar adjusted ICU mortality (aOR [95%CI] = 1.15 [0.97–1.38]; P = .12). While bed occupancy rate ≥ 90% was more frequent in patients admitted afterhours (23.1% vs. 29.1%) or deceased in ICU (23.6% vs. 33.7%), cluster of ICU admissions was more frequent in patients admitted during daytime hours (75.2% vs. 58.9%) or that survived the ICU stay (70.1% vs. 63.9%; P ≤ .001 for all). These measures of strained ICU capacity were not associated with adjusted ICU mortality (P ≥ .10 for both).
Conclusions:  Afterhours ICU admission and measures of strained ICU capacity were associated with crude but not adjusted ICU mortality.
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Validation the performance of New York Sepsis Severity Score compared with Sepsis Severity Score in predicting hospital mortality among sepsis patients

This article by Sathaporn and colleagues was first published on line in the Journal of Critical Care in late June 2019.
Purpose:  The aim of this study was to compare the performance of the New York Sepsis Severity Score (NYSSS) with the Sepsis Severity Score (SSS) and Acute Physiology and Chronic Health Evaluation and Simplified Acute Physiology Scores for predicting mortality in sepsis patients.
Method:  A retrospective analysis was conducted in the intensive care unit. The primary outcome was in-hospital mortality.
Results:  Overall 1680 sepsis patients were enrolled. The hospital mortality rate was 44.4%. The NYSSS underestimated actual mortality with standard mortality ratio (SMR) of 1.28 (95%CI 1.19–1.38). However, the SSS slightly overestimated the actual mortality with an SMR of 0.94 (0.88–1.01). The NYSSS had moderate discrimination with an AUC of 0.772 (0.750–0.794), in contrast to the SSS which had good discrimination with an AUC of 0.889 (0.873–0.904). The AUC of the SSS was statistically higher than that of the NYSSS. The AUCs of both the NYSSS and SSS were significantly lower than other standard severity scores. The calibrations for all severity scores were poor. The SSS had better overall performance than the NYSSS (Brier score 0.149 and 0.201, respectively).
Conclusion:  The SSS had better discrimination and overall performance than the NYSSS. However, both sepsis severity scores were poorly calibrated.
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ICU readmission of patients with cancer: Incidence, risk factors and mortality

This research by AbuSara and colleagues was published online in the Journal of Critical Care in February 2019.
Purpose:  Few studies evaluated ICU readmission in cancer patients. This study aimed to describe the incidence and risk factors for ICU readmission in cancer patients and the association with mortality.
Materials and methods:  The study was a retrospective cohort at a comprehensive cancer center, which included cancer patients who were discharged after their initial ICU admission over a 5-year period.  The characteristics and outcomes of patients who required ICU readmission within 30 days of discharge were compared to those who did not require readmission during the study period. Multivariate analyses were performed to identify factors associated with readmission and to evaluate the association between readmission and mortality.
Results:  Among 1582 patients discharged from the ICU, 313(19.8%) were readmitted after a median of 6 days. The most common readmission diagnoses were respiratory failure and sepsis.  Mechanical ventilation (OR 5.80; 95% CI 4.29–7.84) and thrombocytopenia (OR 1.66; 95% CI 1.16–2.38), on the first ICU admission were associated with readmission. Readmission was associated with a higher risk of 28-day and 90-day mortality, (OR 3.02; CI 2.3–4.00) and (OR 3.47; 95% CI 2.69–4.49), respectively.
Conclusions:  ICU readmission was associated with increased mortality. Mechanical ventilation and thrombocytopenia at the first admission were associated with ICU readmission.
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Association of septic shock definitions and standardized mortality ratio in a contemporary cohort of critically ill patients

This research by Kashyap and colleagues was first published on line in the “Journal of Critical Care” during January 2019.
Purpose:  The newly proposed septic shock definition has provoked a substantial controversy in the emergency and critical care communities. We aim to compare new (SEPSIS-III) versus old (SEPSIS-II) definitions for septic shock in a contemporary cohort of critically ill patients.
Material and methods:  Retrospective cohort of consecutive patients, age ≥ 18 years admitted to intensive care units at the Mayo Clinic between January 2009 and October 2015. We compared patients who met old, new, both, or neither definition of sepsis shock. SMR were calculated using APACHE IV predicted mortality.
Results:  The initial cohort consisted of 16,720 patients who had suspicion of infection, 7463 required vasopressor support. The median (IQR) age was 65(54–75) years and 4167(55.8%) were male. Compared to patients with old definition, the patients with new definition had higher APACHE III score (median IQR); (73 (57–92) vs. 70 (56–89), p < .01); SOFA score; (6 (4–10) vs. 6 (4–9), p < .01), were older (70 (59–79) vs. 64 (54–74) years, p = .03). They also had higher hospital mortality, N (%) 71, (19.7%) vs. 40 (12.6%), p < .01) and a higher SMR (0.66 vs. 0.45, p < .01).
Conclusions:  Compared to SEPSIS-II, SEPSIS-III definition of septic shock identifies patients further along disease trajectory with higher likelihood of poor outcome.
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Severity of illness assessment with application of the APACHE IV predicted mortality and outcome trends analysis in an academic cardiac intensive care unit

This paper by Bennett and colleagues was published in Journal of Critical Care on 24th December 2018.
Purpose:  To assess trends in life support interventions and performance of the automated Acute Physiology and Chronic Health Evaluation (APACHE) IV model at mortality prediction compared with Oxford Acute Severity of Illness Score (OASIS) in a contemporary cardiac intensive care unit (CICU).
Methods and materials:  Retrospective analysis of adults (age ≥ 18 years) admitted to CICU from January 1, 2007, through December 31, 2015. Temporal trends were assessed with linear regression. Discrimination of each risk score for hospital mortality was assessed with use of area under the receiver operating characteristic curve (AUROC) values. Calibration was assessed with Hosmer-Lemeshow goodness-of-fit test.
Results:  The study analyzed 10,004 patients. CICU and hospital mortality rates were 5.7% and 9.1%. APACHE IV predicted death had an AUROC of 0.82 (0.81–0.84) for hospital death, compared with 0.79 for OASIS (P < .05). Calibration was better for OASIS than APACHE IV. Increases were observed in CICU and hospital lengths of stay (both P < .001), APACHE IV predicted mortality (P = .007), Charlson Comorbidity Index (P < .001), noninvasive ventilation use (P < .001), and noninvasive ventilation days (P = .02).
Conclusions:  Contemporary CICU patients are increasingly ill, observed in upward trends in comorbid conditions and life support interventions. APACHE IV predicted death and OASIS showed good discrimination in predicting death in this population. APACHE IV and OASIS may be useful for benchmarking and quality improvement initiatives in the CICU, the former having better discrimination.
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Linezolid-induced thrombocytopenia increases mortality risk in intensive care unit patients, a 10 year retrospective study

This article by Kim and colleagues was published in the Journal of Clinical Pharmacy and Therapeutics September 2018 issue.
What is known and objective:  Linezolid-induced thrombocytopenia is one of the many confounding conditions in critically ill patients. It is rare but prognostic importance of linezolid-induced thrombocytopenia in ICU population has not been well investigated. The study is to assess the incidence and risk factors of linezolid-induced thrombocytopenia in ICU patients.
Methods:  We conducted a retrospective study with ICU patients treated with linezolid between January 2005 and December 2015 at the adult medical, surgical, emergency, and neurological ICUs at 1500-bed tertiary university medical center.
Results and Discussion:  There were 60 patients (mean age: 69.8 ± 11.9), 29 (48.3%) who developed linezolid-induced thrombocytopenia determined by the Naranjo algorithm on a case-by-case basis during the study period. The patients with linezolid-induced thrombocytopenia had a higher rate of any malignancy (41.4% vs 9.7%, P = 0.007), elevated baseline creatinine levels (median [interquartile range; IQR]: 1.7 mg/dL [0.9-2.5] vs 0.9 mg/dL [0.6-1.3]; P = 0.042), and lower baseline platelet counts (median [IQR] 160 × 109 /L [128-230] vs 194 × 109 /L [118-285]; P = 0.296) than patients without linezolid-induced thrombocytopenia. The patients who developed thrombocytopenia received more platelet transfusions (34.5% vs 6.5%, P = 0.009) and had higher ICU mortality rates (62.1% vs 32.3%, P = 0.037). Logistic regression analysis revealed the following significant risk factors for linezolid-induced thrombocytopenia: presence of any malignancy (odds ratio; OR [95% confidence interval; CI]: 8.667 [1.986-37.831]) and an elevated baseline serum creatinine level (OR: 1.673, CI: 1.046-2.675]).
What is New and Conclusion:  Critically ill patients with any malignancy or an elevated baseline creatinine level who were treated with linezolid in the ICU were more likely to develop thrombocytopenia. More importantly, mortality increased with patients who developed linezolid-induced thrombocytopenia compared to those did not.
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Sepsis incidence and mortality are underestimated in Australian intensive care unit administrative data

This research by Heldens and colleagues was published in the Medical Journal of Australia in September 2018.
Objectives:  To compare estimates of the incidence and mortality of sepsis and septic shock among patients in Australian intensive care units (ICUs) according to clinical diagnoses or binational intensive care database (ANZICS CORE) methodology.
Design, Setting, Participants:  Prospective inception cohort study (3-month inception period, 1 October – 31 December 2016, with 60-day follow-up); daily screening of all patients in a tertiary hospital 60-bed multidisciplinary ICU.
Main Outcomes:  Diagnoses of sepsis and septic shock according to clinical criteria and database criteria; in-hospital mortality (censored at 60 days).
Results:  Of 864 patients admitted to the ICU, 146 (16.9%) were diagnosed with sepsis by clinical criteria and 98 (11%) according to the database definition (P < 0.001); the sensitivity of the database criteria for sepsis was 52%, the specificity 97%. Forty-nine patients (5.7%) were diagnosed with septic shock by clinical criteria and 83 patients (9.6%) with the database definition (P < 0.001); the sensitivity of the database criteria for septic shock was 65%, the specificity 94%. In-hospital mortality of patients diagnosed with sepsis was greater in the clinical diagnosis group (39/146, 27%) than in the database group (17/98, 17%; P = 0.12); for septic shock, mortality was significantly higher in the clinical diagnosis group (13/83, 16%) than in the database group (18/49, 37%; P = 0.006).
Conclusions:  When compared with the reference standard – prospective clinical diagnosis – ANZICS CORE database criteria significantly underestimate the incidence of sepsis and overestimate the incidence of septic shock, and also result in lower estimated hospital mortality rates for each condition.
The full text of this article is freely available via this link.