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.

The organisation of critical care for burn patients in the UK: epidemiology and comparison of mortality prediction models

This article by Toft-Petersen and colleagues was published on-line in Anaesthesia in May 2018.
In the UK, a network of specialist centres has been set up to provide critical care for burn patients. However, some burn patients are admitted to general intensive care units. Little is known about the casemix of these patients and how it compares with patients in specialist burn centres. It is not known whether burn-specific or generic risk prediction models perform better when applied to patients managed in intensive care units. We examined admissions for burns in the Case Mix Programme Database from April 2010 to March 2016. The casemix, activity and outcome in general and specialist burn intensive care units were compared and the fit of two burn-specific risk prediction models (revised Baux and Belgian Outcome in Burn Injury models) and one generic model (Intensive Care National Audit and Research Centre model) were compared. Patients in burn intensive care units had more extensive injuries compared with patients in general intensive care units (median (IQR [range]) burn surface area 16 (7-32 [0-98])% vs. 8 (1-18 [0-100])%, respectively) but in-hospital mortality was similar (22.8% vs. 19.0%, respectively). The discrimination and calibration of the generic Intensive Care National Audit and Research Centre model was superior to the revised Baux and Belgian Outcome in Burn Injury burn-specific models for patients managed on both specialist burn and general intensive care units.
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The Association of Age With Short-Term and Long-Term Mortality in Adults Admitted to the Intensive Care Unit

This article was published Journal of intensive care medicine October 2017 by Seethala et al
Background:  Based on the current literature, it is unclear whether advanced age itself leads to higher mortality in critically ill patients or whether it is due to the greater number of comorbidities in the elderly patients. We hypothesized that increasing age would increase the odds of short-term and long-term mortality after adjusting for baseline comorbidities in intensive care unit (ICU) patients.
Methods:  We performed a retrospective cohort study of 57 160 adults admitted to any ICU over 5 years at 2 academic tertiary care centers. Patients were divided into age-groups, 18 to 39, 40 to 59, 60 to 79, and ≥80. The primary outcomes were 30-day and 365-day mortality. Results were analyzed with multivariate logistic regression adjusting for demographics and the Elixhauser-van Walraven Comorbidity Index.
Results:  The adjusted 30-day mortality odds ratios (ORs) were 1.39 (95% confidence interval [CI]: 1.21-1.60), 2.00 (95% CI: 1.75-2.28), and 3.33 (95% CI: 2.90-3.82) for age-groups 40 to 59, 60 to 79, and ≥80, respectively, using the age-group 18 to 39 as the reference. The adjusted 365-day mortality ORs were 1.46 (95% CI: 1.32-1.61), 2.10 (95% CI: 1.91-2.31), and 2.96 (95% CI: 2.67-3.27).
Conclusions:  In critically ill patients, increasing age is associated with higher odds of short-term and long-term death after correcting for existing comorbidities.
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