Transfusion with Cryoprecipitate for Very Low Fibrinogen Levels Does Not Affect Bleeding or Survival in Critically Ill Cirrhosis Patients

2021 ◽  
Author(s):  
Isadore Budnick ◽  
Jessica Davis ◽  
Anirudh Sundararaghavan ◽  
Samuel Konkol ◽  
Chelsea Lau ◽  
...  
Keyword(s):  
Disease Severity ◽  
Critically Ill ◽  
Tertiary Care ◽  
Severity Of Illness ◽  
Meld Score ◽  
Independent Effect ◽  
Bleeding Complications ◽  
Bleeding Events ◽  
Acute Bleeding ◽  
Transplant Center

Background: Fibrinogen (FIB) levels less than 150 mg/dL have been associated with increased rates of bleeding and lower survival in critically ill cirrhosis patients. Objective: We aimed to determine if treatment with cryoprecipitate (CRYO) for low FIB levels were associated with bleeding complications or survival. Patients / Methods: 237 cirrhosis patients admitted to an intensive care unit at a tertiary care liver transplant center with initial FIB levels less than 150 mg/dL were retrospectively assessed for CRYO transfusion, bleeding events, and survival outcomes. Results: The mean MELD score was 27.2 (95% CI 26.0 - 28.3) and CLIF-C Acute on Chronic Liver Failure (ACLF) score was 53.4 (51.9 - 54.8). Ninety-nine (41.8%) were admitted for acute bleeding and the remainder were admitted for non-bleeding illnesses. FIB level on admission correlated strongly with disease severity. After adjusting for disease severity, FIB on admission was not an independent predictor of 30-day survival (HR 0.99, 95% CI 0.99 - 1.01, p = 0.68). CRYO transfusion increased FIB levels but had no independent effect on mortality or bleeding complications (HR 1.10, 95% CI 0.72 - 1.70, p = 0.65). Conclusions: In cirrhosis patients with critical illness, low FIB levels on presentation reflect severity of illness but are not independently associated with 30-day mortality. Treatment of low FIB with CRYO also does not affect survival or bleeding complications suggesting FIB is an additional marker of severity of illness but is not itself a direct factor in the pathophysiology of bleeding in critically ill cirrhosis patients.

Mobilization Therapy in the Pediatric Intensive Care Unit: A Multidisciplinary Quality Improvement Initiative

2018 ◽  
Vol 27 (3) ◽  
pp. 194-203 ◽  
Author(s):  
Blair R. L. Colwell ◽  
Cydni N. Williams ◽  
Serena P. Kelly ◽  
Laura M. Ibsen
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Quality Improvement ◽  
Critically Ill ◽  
Pediatric Intensive Care Unit ◽  
Tertiary Care ◽  
Severity Of Illness ◽  
Pediatric Intensive Care ◽  
Critically Ill Children ◽  
Improvement Project

Background Mobilization is safe and associated with improved outcomes in critically ill adults, but little is known about mobilization of critically ill children. Objective To implement a standardized mobilization therapy protocol in a pediatric intensive care unit and improve mobilization of patients. Methods A goal-directed mobilization protocol was instituted as a quality improvement project in a 20-bed cardiac and medical-surgical pediatric intensive care unit within an academic tertiary care center. The mobilization goal was based on age and severity of illness. Data on severity of illness, ordered activity limitations, baseline functioning, mobilization level, complications of mobilization, and mobilization barriers were collected. Goal mobilization was defined as a ratio of mobilization level to severity of illness of 1 or greater. Results In 9 months, 567 patient encounters were analyzed, 294 (52%) of which achieved goal mobilization. The mean ratio of mobilization level to severity of illness improved slightly but nonsignificantly. Encounters that met mobilization goals were in younger (P = .04) and more ill (P < .001) patients and were less likely to have barriers (P < .001) than encounters not meeting the goals. Complication rate was 2.5%, with no difference between groups (P = .18). No serious adverse events occurred. Conclusions A multidisciplinary, multiprofessional, goal-directed mobilization protocol achieved goal mobilization in more than 50% of patients in this pediatric intensive care unit. Undermobilized patients were older, less ill, and more likely to have mobilization barriers at the patient and provider level.

scholarly journals Novel Coronavirus Infection (COVID-19) Related Thrombotic and Bleeding Complications in Critically Ill Patients: Experience from an Academic Medical Center

2021 ◽  
Vol 10 (23) ◽  
pp. 5652
Author(s):  
Thejus Jayakrishnan ◽  
Aaron Haag ◽  
Shane Mealy ◽  
Corbyn Minich ◽  
Abraham Attah ◽  
...  
Keyword(s):  
Critically Ill ◽  
Major Bleeding ◽  
Bleeding Complications ◽  
P Value ◽  
Bleeding Events ◽  
Coagulation Parameters ◽  
Therapeutic Anticoagulation ◽  
Coronavirus Infection ◽  
Novel Coronavirus ◽  
Prophylactic Anticoagulation

Introduction: Thrombosis and bleeding are recognized complications of the novel coronavirus infection (COVID-19), with a higher incidence described particularly in the critically ill. Methods: A retrospective review of COVID-19 patients admitted to our intensive care units (ICU) between 1 January 2020 and 31 December 2020 was performed. Primary outcomes included clinically significant thrombotic and bleeding events (according to the ISTH definition) in the ICU. Secondary outcomes included mortality vis-a-vis the type of anticoagulation. Results: The cohort included 144 consecutive COVID-19 patients with a median age of 64 years (IQR 54.5–75). The majority were male (85 (59.0%)) and Caucasian (90 (62.5%)) with a median BMI of 30.5 kg/m2 (IQR 25.7–36.1). The median APACHE score at admission to the ICU was 12.5 (IQR 9.5–22). The coagulation parameters at admission were a d-dimer level of 109.2 mg/mL, a platelet count of 217.5 k/mcl, and an INR of 1.4. The anticoagulation strategy at admission included prophylactic anticoagulation for 97 (67.4%) patients and therapeutic anticoagulation for 35 (24.3%) patients, while 12 (8.3%) patients received no anticoagulation. A total of 29 patients (20.1%) suffered from thrombotic or major bleeding complications. These included 17 thrombus events (11.8%)—8 while on prophylactic anticoagulation (7 regular dose and 1 intermediate dose) and 9 while on therapeutic anticoagulation (p-value = 0.02)—and 19 major bleeding events (13.2%) (4 on no anticoagulation, 7 on prophylactic (6 regular dose and 1 intermediate dose), and 8 on therapeutic anticoagulation (p-value = 0.02)). A higher thrombosis risk among patients who received remdesivir (18.8% vs. 5.3% (p-value = 0.01)) and convalescent serum (17.3% vs. 5.8% (p-value = 0.03%)) was noted, but no association with baseline characteristics (age, sex, race, comorbidity), coagulation parameters, or treatments (steroids, mechanical ventilation) could be identified. There were 10 pulmonary embolism cases (6.9%). A total of 99 (68.8%) patients were intubated, and 66 patients (45.8%) died. Mortality was higher, but not statistically significant, in patients with thrombotic or bleeding complications—58.6% vs. 42.6% (p-value = 0.12)—and higher in the bleeding (21.2%) vs. thrombus group (12.1%), p-value = 0.06. It did not significantly differ according to the type of anticoagulation used or the coagulation parameters. Conclusions: This study describes a high incidence of thrombotic and bleeding complications among critically ill COVID-19 patients. The findings of thrombotic events in patients on anticoagulation and major bleeding events in patients on no or prophylactic anticoagulation pose a challenging clinical dilemma in the issue of anticoagulation for COVID-19 patients. The questions raised by this study and previous literature on this subject demonstrate that the role of anticoagulation in COVID-19 patients is worthy of further investigation.

Prevalence, Correlates and Management of Hyperglycemia in Diabetic Non-critically Ill Patients at a Tertiary Care Center in Lebanon

2019 ◽  
Vol 15 (2) ◽  
pp. 133-140 ◽  
Author(s):  
Ghada El Khoury ◽  
Hanine Mansour ◽  
Wissam K. Kabbara ◽  
Nibal Chamoun ◽  
Nadim Atallah ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Care Center ◽  
Descriptive Analysis ◽  
Tertiary Care ◽  
Multivariable Analysis ◽  
Length Of Hospital Stay ◽  
Retrospective Chart Review ◽  
Diabetic Patients

Background: Diabetes Mellitus is a chronic metabolic disease that affects 387 million people around the world. Episodes of hyperglycemia in hospitalized diabetic patients are associated with poor clinical outcomes and increased morbidity and mortality. Therefore, prevention of hyperglycemia is critical to decrease the length of hospital stay and to reduce complications and readmissions. Objective: The study aims to examine the prevalence of hyperglycemia and assess the correlates and management of hyperglycemia in diabetic non-critically ill patients. Methods: The study was conducted on the medical wards of a tertiary care teaching hospital in Lebanon. A retrospective chart review was conducted from January 2014 until September 2015. Diabetic patients admitted to Internal Medicine floors were identified. Descriptive analysis was first carried out, followed by a multivariable analysis to study the correlates of hyperglycemia occurrence. Results: A total of 235 medical charts were reviewed. Seventy percent of participants suffered from hyperglycemia during their hospital stay. The identified significant positive correlates for inpatient hyperglycemia, were the use of insulin sliding scale alone (OR=16.438 ± 6.765-39.941, p=0.001) and the low frequency of glucose monitoring. Measuring glucose every 8 hours (OR= 3.583 ± 1.506-8.524, p=0.004) and/or every 12 hours (OR=7.647 ± 0.704-79.231, p=0.0095) was associated with hyperglycemia. The major factor perceived by nurses as a barrier to successful hyperglycemia management was the lack of knowledge about appropriate insulin use (87.5%). Conclusion: Considerable mismanagement of hyperglycemia in diabetic non-critically ill patients exists; indicating a compelling need for the development and implementation of protocol-driven insulin order forms a comprehensive education plan on the appropriate use of insulin.

Chemotherapy-sparing treatment of haemophagocytic lymphohistiocytosis with intravenous immunoglobulins and corticosteroids

2020 ◽  
Vol 13 (5) ◽  
pp. e234490
Author(s):  
Evan C Chen ◽  
Jonathan A Stefely ◽  
Bimalangshu R Dey ◽  
Walter H Dzik
Keyword(s):  
Effective Treatment ◽  
Disease Severity ◽  
Critically Ill ◽  
Intravenous Immunoglobulins ◽  
Current Treatment ◽  
Haemophagocytic Lymphohistiocytosis ◽  
Tailored Therapy ◽  
Fatal Disease ◽  
Therapeutic Challenge

Haemophagocytic lymphohistiocytosis (HLH) can be a rapidly fatal disease. Current treatment in adults is extrapolated from the HLH-2004 protocol that specifies a regimen of etoposide, dexamethasone and cyclosporine. However, HLH presents as a spectrum of disease severity. A therapeutic challenge arises for milder cases where the harms of potent chemotherapy such as etoposide may outweigh its benefit. We present a case of an adult with HLH who developed significant pancytopenia but was otherwise not critically ill and who responded to treatment with a chemotherapy-sparing approach consisting of intravenous immunoglobulins and corticosteroids alone. The case illustrates that tailored therapy may allow effective treatment of the disorder while minimising therapy-related toxicities.

Delayed onset bleed after percutaneous kidney biopsy: is it the same as early bleed?

2021 ◽  
pp. 028418512098881
Author(s):  
Dharmendra Bhadauria ◽  
Leena Jose ◽  
Ravi Kushwaha ◽  
Anupma Kaul ◽  
Raghu Nandan ◽  
...  
Keyword(s):  
Major Bleeding ◽  
Kidney Biopsy ◽  
Tertiary Care ◽  
North India ◽  
Bleeding Complications ◽  
Control Group ◽  
Blood Transfusions ◽  
Delayed Bleeding ◽  
Delayed Onset ◽  
Good Patient Outcome

Background While the majority of bleeding complications after a percutaneous kidney biopsy (PKB) occur early (≤24 h), delayed onset bleeding complications (>24 h) have been rarely reported and can be catastrophic for the patient. Purpose To describe the incidence, risk factors, and outcomes of delayed bleeding complications after PKB. Material and Methods We retrospectively studied native and graft kidney biopsies in patients who developed delayed bleeding complications (>24 h) after the biopsy performed in the Department of Nephrology and Renal Transplantation of a tertiary care medical institution in north India between January 2014 to December 2018. Results Of the 4912 renal biopsies reviewed, 20 patients (16 men, 4 women; 0.40%) had a delayed biopsy bleeding complication. Of these patients, 95% had major bleeding complications requiring blood transfusions and 85% needed intervention like gelfoam/coil embolization. Despite intervention, one patient (5%) had mortality due to complications of bleeding and sepsis. When compared to a control group of patients with early biopsy bleed, patients with the delayed biopsy bleed had similar demographic and clinical profiles except for higher pre-biopsy hemoglobin and lower systolic and diastolic blood pressure. Conclusion A post-PKB delayed onset bleed is not uncommon, and the vast majority of these patients had major bleeding complications requiring blood transfusions and/or intervention like embolization. They had a similar demographic and clinical profile presentation as early bleed patients. Meticulous outpatient monitoring and patient education after discharge may be useful to detect this complication promptly and to intervene early to have good patient outcome.

Aspirin I.V. Loading during Elective Percutaneous Coronary Intervention

Pharmacology ◽  
2021 ◽  
pp. 1-5
Author(s):  
David Naguib ◽  
Carolin Helten ◽  
Saif Zako ◽  
Philipp Mourikis ◽  
René M’Pembele ◽  
...  
Keyword(s):  
Pilot Study ◽  
Light Transmission ◽  
Platelet Reactivity ◽  
Coronary Intervention ◽  
Bleeding Complications ◽  
Loading Dose ◽  
Bleeding Events ◽  
Elective Percutaneous Coronary Intervention ◽  
Percutaneous Coronary ◽  
The Impact

Additional loading dose of acetylsalicylic acid (ASA) during percutaneous coronary interventions (PCIs) despite permanent oral ASA medication is frequently applicated. The impact on platelet reactivity and clinical events is not known. In this pilot study, we aimed to analyze high on-treatment platelet reactivity (HTPR) to aspirin in patients undergoing elective PCI. Platelet reactivity was measured using light-transmission aggregometry in 100 patients on permanent low-dose ASA medication undergoing elective PCI. Platelet reactivity measured by arachidonic acid-induced maximum of aggregation (MoA) in patients with versus without additional peri-procedural ASA loading (500 mg i.v.) was compared. HTPR was defined as MoA &#x3e;20% for ASA. Major adverse cerebro- and cardiovascular events (MACCEs) and bleeding events were evaluated during hospital course. HTPR rate was similar in both groups (HTPR to ASA: loading vs. control 6% vs. 16%, odds ratio [OR] = 0.33, 95% confidence interval [CI] 0.08–1.35, <i>p</i> = 0.12). In-hospital MACCEs were not different between groups (MACCE: loading vs. control: 0 vs. 0 patient, OR = 1.32, 95% CI 0.03–67.95, <i>p</i> = 0.89). Thrombolysis in myocardial infarction minimal bleedings were numerically higher in patients without ASA loading dose. In this pharmacodynamic pilot study, additional ASA loading did not reduce HTPR to ASA. Furthermore, ASA loading did not increase in-hospital MACCE and bleeding complications.

scholarly journals Splenic uptake on FDG PET/CT correlates with Kikuchi-Fujimoto disease severity

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Hye Seong ◽  
Yong Hyu Jeong ◽  
Woon Ji Lee ◽  
Jun Hyoung Kim ◽  
Jung Ho Kim ◽  
...  
Keyword(s):  
Disease Severity ◽  
Fdg Pet ◽  
Tertiary Care ◽  
Clinical Manifestations ◽  
Standardized Uptake Value ◽  
Total Lesion Glycolysis ◽  
Positron Emission ◽  
Pet Ct ◽  
Systemic Symptoms ◽  
Fdg Pet Ct

AbstractKikuchi-Fujimoto disease (KFD) is usually self-limiting, but prolonged systemic symptoms often result in frequent hospital visits, long admission durations, or missed workdays. We investigated the role of fluorine-18 fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in assessing KFD severity. We reviewed the records of 31 adult patients with pathologically confirmed KFD who underwent 18F-FDG PET/CT between November 2007 and April 2018 at a tertiary-care referral hospital. Disease severity was assessed using criteria based on clinical manifestations of advanced KFD. Systemic activated lymph nodes and severity of splenic activation were determined using semi-quantitative and volumetric PET/CT parameters. The median of the mean splenic standardized uptake value (SUVmean) was higher in patients with severe KFD than those with mild KFD (2.38 ± 1.18 vs. 1.79 ± 0.99, p = 0.058). Patients with severe KFD had more systemically activated volume and glycolytic activity than those with mild KFD (total lesion glycolysis: 473.5 ± 504.4 vs. 201.6 ± 363.5, p = 0.024). Multivariate logistic regression showed that myalgia (odds ratio [OR] 0.035; 95% confidence interval [CI] 0.001–0.792; p = 0.035), total lymph node SUVmax (cutoff 9.27; OR 24.734; 95% CI 1.323–462.407; p = 0.032), and spleen SUVmean (cutoff 1.79; OR 37.770; 95% CI 1.769–806.583; p = 0.020) were significantly associated with severe KFD. 18F-FDG PET/CT could be useful in assessing KFD severity.

scholarly journals MRI-based radiomic feature analysis of end-stage liver disease for severity stratification

2021 ◽  
Author(s):  
Jennifer Nitsch ◽  
Jordan Sack ◽  
Michael W. Halle ◽  
Jan H. Moltz ◽  
April Wall ◽  
...  
Keyword(s):  
Disease Severity ◽  
Prediction Models ◽  
Blood Parameters ◽  
Meld Score ◽  
Poor Correlation ◽  
Discrimination Ability ◽  
Random Forest Classification ◽  
Forest Classification ◽  
Academic Center ◽  
End Stage

Abstract Purpose We aimed to develop a predictive model of disease severity for cirrhosis using MRI-derived radiomic features of the liver and spleen and compared it to the existing disease severity metrics of MELD score and clinical decompensation. The MELD score is compiled solely by blood parameters, and so far, it was not investigated if extracted image-based features have the potential to reflect severity to potentially complement the calculated score. Methods This was a retrospective study of eligible patients with cirrhosis ($$n=90$$ n = 90 ) who underwent a contrast-enhanced MR screening protocol for hepatocellular carcinoma (HCC) screening at a tertiary academic center from 2015 to 2018. Radiomic feature analyses were used to train four prediction models for assessing the patient’s condition at time of scan: MELD score, MELD score $$\ge $$ ≥ 9 (median score of the cohort), MELD score $$\ge $$ ≥ 15 (the inflection between the risk and benefit of transplant), and clinical decompensation. Liver and spleen segmentations were used for feature extraction, followed by cross-validated random forest classification. Results Radiomic features of the liver and spleen were most predictive of clinical decompensation (AUC 0.84), which the MELD score could predict with an AUC of 0.78. Using liver or spleen features alone had slightly lower discrimination ability (AUC of 0.82 for liver and AUC of 0.78 for spleen features only), although this was not statistically significant on our cohort. When radiomic prediction models were trained to predict continuous MELD scores, there was poor correlation. When stratifying risk by splitting our cohort at the median MELD 9 or at MELD 15, our models achieved AUCs of 0.78 or 0.66, respectively. Conclusions We demonstrated that MRI-based radiomic features of the liver and spleen have the potential to predict the severity of liver cirrhosis, using decompensation or MELD status as imperfect surrogate measures for disease severity.

scholarly journals Severe liver dysfunction complicating course of COVID-19 in the critically ill: multifactorial cause or direct viral effect?

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Kevin Roedl ◽  
Dominik Jarczak ◽  
Andreas Drolz ◽  
Dominic Wichmann ◽  
Olaf Boenisch ◽  
...  
Keyword(s):  
Critically Ill ◽  
Liver Dysfunction ◽  
Critically Ill Patients ◽  
Severity Of Illness ◽  
University Hospital ◽  
Severe Liver ◽  
Saps Ii ◽  
Severe Liver Dysfunction ◽  
Global Threat ◽  
The University

Abstract Background SARS-CoV-2 caused a pandemic and global threat for human health. Presence of liver injury was commonly reported in patients with coronavirus disease 2019 (COVID-19). However, reports on severe liver dysfunction (SLD) in critically ill with COVID-19 are lacking. We evaluated the occurrence, clinical characteristics and outcome of SLD in critically ill patients with COVID-19. Methods Clinical course and laboratory was analyzed from all patients with confirmed COVID-19 admitted to ICU of the university hospital. SLD was defined as: bilirubin ≥ 2 mg/dl or elevation of aminotransferase levels (> 20-fold ULN). Results 72 critically ill patients were identified, 22 (31%) patients developed SLD. Presenting characteristics including age, gender, comorbidities as well as clinical presentation regarding COVID-19 overlapped substantially in both groups. Patients with SLD had more severe respiratory failure (paO2/FiO2: 82 (58–114) vs. 117 (83–155); p < 0.05). Thus, required more frequently mechanical ventilation (95% vs. 64%; p < 0.01), rescue therapies (ECMO) (27% vs. 12%; p = 0.106), vasopressor (95% vs. 72%; p < 0.05) and renal replacement therapy (86% vs. 30%; p < 0.001). Severity of illness was significantly higher (SAPS II: 48 (39–52) vs. 40 (32–45); p < 0.01). Patients with SLD and without presented viremic during ICU stay in 68% and 34%, respectively (p = 0.002). Occurrence of SLD was independently associated with presence of viremia [OR 6.359; 95% CI 1.336–30.253; p < 0.05] and severity of illness (SAPS II) [OR 1.078; 95% CI 1.004–1.157; p < 0.05]. Mortality was high in patients with SLD compared to other patients (68% vs. 16%, p < 0.001). After adjustment for confounders, SLD was independently associated with mortality [HR3.347; 95% CI 1.401–7.999; p < 0.01]. Conclusion One-third of critically ill patients with COVID-19 suffer from SLD, which is associated with high mortality. Occurrence of viremia and severity of illness seem to contribute to occurrence of SLD and underline the multifactorial cause.

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