The Association between Obesity and Outcomes in Critically Ill Patients

BACKGROUND: Obesity rates are increasing worldwide, particularly in North America. The impact of obesity on the outcome of critically ill patients is unclear.METHODS: A prospective observational cohort study of consecutive patients admitted to a tertiary critical care unit in Canada between January 10, 2008 and March 31, 2009 was conducted. Exclusion criteria were age <18 years, admission <24 h, planned cardiac surgery, pregnancy, significant ascites, unclosed surgical abdomen and brain death on admission. Height, weight and abdominal circumference were measured at the time of intensive care unit (ICU) admission. Coprimary end points were ICU mortality and a composite of ICU mortality, reintubation, ventilator-associated pneumonia, line sepsis and ICU readmission. Subjects were stratified as obese or nonobese, using two separate metrics: body mass index (BMI) ≥30 kg/m2and a novel measurement of 75th percentile for waist-to-height ratio (WHR).RESULTS: Among 449 subjects with a BMI ≥18.5 kg/m2, both BMI and WHR were available for comparative analysis in 348 (77.5%). Neither measure of obesity was associated with the primary end points. BMI ≥30 kg/m2was associated with a lower odds of six-month mortality than the BMI <30 kg/m2group (adjusted OR 0.59 [95% CI 0.36 to 0.97]; P=0.04) but longer intubation times (adjusted RR 1.56 [95% CI 1.17 to 2.07]; P=0.003) and longer ICU length of stay (adjusted RR 1.67 [95% CI 1.21 to 2.31]; P=0.002). Conversely, measurement of 75th percentile for WHR was associated only with decreased ICU readmission (OR 0.23 [95% CI 0.07 to 0.79]; P=0.02).CONCLUSIONS: Obesity was not necessarily associated with worse outcomes in critically ill patients.

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Outcomes of non-COVID-19 critically ill patients during the COVID-19 pandemic

Wiener klinische Wochenschrift ◽

10.1007/s00508-021-01857-4 ◽

2021 ◽

Author(s):

Răzvan Bologheanu ◽

Mathias Maleczek ◽

Daniel Laxar ◽

Oliver Kimberger

Keyword(s):

Intensive Care ◽

Length Of Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Medical Specialty ◽

Routine Care ◽

Treatment Pathways ◽

Icu Length Of Stay ◽

Matched Study ◽

The Impact

Summary Background Coronavirus disease 2019 (COVID-19) disrupts routine care and alters treatment pathways in every medical specialty, including intensive care medicine, which has been at the core of the pandemic response. The impact of the pandemic is inevitably not limited to patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their outcomes; however, the impact of COVID-19 on intensive care has not yet been analyzed. Methods The objective of this propensity score-matched study was to compare the clinical outcomes of non-COVID-19 critically ill patients with the outcomes of prepandemic patients. Critically ill, non-COVID-19 patients admitted to the intensive care unit (ICU) during the first wave of the pandemic were matched with patients admitted in the previous year. Mortality, length of stay, and rate of readmission were compared between the two groups after matching. Results A total of 211 critically ill SARS-CoV‑2 negative patients admitted between 13 March 2020 and 16 May 2020 were matched to 211 controls, selected from a matching pool of 1421 eligible patients admitted to the ICU in 2019. After matching, the outcomes were not significantly different between the two groups: ICU mortality was 5.2% in 2019 and 8.5% in 2020, p = 0.248, while intrahospital mortality was 10.9% in 2019 and 14.2% in 2020, p = 0.378. The median ICU length of stay was similar in 2019: 4 days (IQR 2–6) compared to 2020: 4 days (IQR 2–7), p = 0.196. The rate of ICU readmission was 15.6% in 2019 and 10.9% in 2020, p = 0.344. Conclusion In this retrospective single center study, mortality, ICU length of stay, and rate of ICU readmission did not differ significantly between patients admitted to the ICU during the implementation of hospital-wide COVID-19 contingency planning and patients admitted to the ICU before the pandemic.

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Pharmacokinetic/Pharmacodynamic Target Attainment Based on Measured Versus Predicted Unbound Ceftriaxone Concentrations in Critically Ill Patients with Pneumonia: An Observational Cohort Study

Antibiotics ◽

10.3390/antibiotics10050557 ◽

2021 ◽

Vol 10 (5) ◽

pp. 557

Author(s):

Matthias Gijsen ◽

Erwin Dreesen ◽

Ruth Van Daele ◽

Pieter Annaert ◽

Yves Debaveye ◽

...

Keyword(s):

Renal Function ◽

Cohort Study ◽

Protein Binding ◽

Critically Ill ◽

Critically Ill Patients ◽

Observational Cohort Study ◽

Target Attainment ◽

Binding Model ◽

Observational Cohort ◽

The Impact

The impact of ceftriaxone pharmacokinetic alterations on protein binding and PK/PD target attainment still remains unclear. We evaluated pharmacokinetic/pharmacodynamic (PK/PD) target attainment of unbound ceftriaxone in critically ill patients with severe community-acquired pneumonia (CAP). Besides, we evaluated the accuracy of predicted vs. measured unbound ceftriaxone concentrations, and its impact on PK/PD target attainment. A prospective observational cohort study was carried out in adult patients admitted to the intensive care unit with severe CAP. Ceftriaxone 2 g q24h intermittent infusion was administered to all patients. Successful PK/PD target attainment was defined as unbound trough concentrations above 1 or 4 mg/L throughout the whole dosing interval. Acceptable overall PK/PD target attainment was defined as successful target attainment in ≥90% of all dosing intervals. Measured unbound ceftriaxone concentrations (CEFu) were compared to unbound concentrations predicted from various protein binding models. Thirty-one patients were included. The 1 mg/L and 4 mg/L targets were reached in 26/32 (81%) and 15/32 (47%) trough samples, respectively. Increased renal function was associated with the failure to attain both PK/PD targets. Unbound ceftriaxone concentrations predicted by the protein binding model developed in the present study showed acceptable bias and precision and had no major impact on PK/PD target attainment. We showed suboptimal (i.e., <90%) unbound ceftriaxone PK/PD target attainment when using a standard 2 g q24h dosing regimen in critically ill patients with severe CAP. Renal function was the major driver for the failure to attain the predefined targets, in accordance with results found in general and septic ICU patients. Interestingly, CEFu was reliably predicted from CEFt without major impact on clinical decisions regarding PK/PD target attainment. This suggests that, when carefully selecting a protein binding model, CEFu does not need to be measured. As a result, the turn-around time and cost for ceftriaxone quantification can be substantially reduced.

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Early Versus Late Use of Dexamethasone in Critically Ill Patients With COVID-19: A Multicenter, Prospective Cohort Study

10.21203/rs.3.rs-349677/v1 ◽

2021 ◽

Author(s):

Khalid Al Sulaiman ◽

Alaa Alhubaishi ◽

Ohoud Al Juhani ◽

Khalid Eljaaly ◽

Omar Al Harbi ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Kidney Injury ◽

Early Initiation ◽

P Value ◽

Icu Mortality ◽

Icu Admission ◽

Icu Length Of Stay ◽

Beta Coefficient ◽

Multicenter Prospective Cohort Study

Abstract Background: Corticosteroids, especially dexamethasone, showed a survival benefit in critically ill COVID 19 patients. However, it is unclear whether the timing of dexamethasone initiation is associated with positive outcomes. The aim of this study is to evaluate the timing of dexamethasone initiation and 30-day ICU mortality in critically ill patients with COVID19. Methods: A multicenter, non-interventional, prospective study for all adult COVID19 admitted to intensive care units (ICUs) who received systemic dexamethasone between March 01 to December 31, 2020. Patients were divided into two groups based on the timing for dexamethasone initiation (early vs. late). Early use defined as the initiation of dexamethasone within three days of ICU admission. Multivariate logistic and generalized linear regression were used. We considered a P value of < 0.05 statistically significant. Results: A total of 475 patients were included in the study; dexamethasone was initiated early within three days of ICU admission in 433 patients. Early initiation of dexamethasone was associated with lower 30-day ICU mortality (OR [95%CI]: 0.43 [0.23, 0.81], p-value = 0.01), and acute kidney injury during ICU stay, (OR [95%CI]: 0.45 [0.21, 0.94], p-value = 0.03). Additionally, among survivors, early initiation was associated with shorter MV duration (beta coefficient [95% CI]: -0.94 [-1.477, -0.395], p-value = 0.0001), ICU length of stay (LOS) (beta coefficient [95%CI]: -0.73 [-0.9971, -0.469], p-value = 0.0001), and hospital LOS (beta coefficient [95%CI]: -0.68 [-0.913, -0.452], p-value = 0.0001). Conclusion: Early initiation of dexamethasone within three days of ICU admission in COVID-19 critically ill patients was associated with a mortality benefit. Additionally, it was associated with shorter MV duration, hospital, and ICU LOS.

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A Differential Therapeutic Consideration for use of Corticosteroids According to Established COVID-19 Clinical Phenotypes in Critically Ill Patients

10.21203/rs.3.rs-525667/v1 ◽

2021 ◽

Author(s):

Gerard Moreno ◽

Manuel Ruíz- Botella ◽

Ignacio Martin-Loeches ◽

Josep Gómez Alvarez ◽

María Jiménez Herrera ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Cox Regression ◽

Cox Proportional Hazards ◽

High Dose ◽

Icu Mortality ◽

Clinical Phenotypes ◽

Biphasic Effect ◽

The Impact ◽

Assumption Violation

Abstract Background: The steroids are currently used as standard treatment for severe COVID-19. However, the evidence is weak. Our aim is to determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes.Methods: A secondary analysis derived from multicenter, observational study of adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). The primary outcome was ICU mortality. We performed a Multivariate analysis after propensity score full matching (PS), Cox proportional hazards (CPH), Cox covariate time interaction (TIR), Weighted Cox Regression (WCR) and Fine-Gray analysis(sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. Results: A total of 2,017 patients were analyzed, 1171(58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR:1.0,95%CI:0.98-1.15). Corticosteroids were administered in 298/537(55.5%) patients of “A” phenotype and their use was not associated with ICU mortality (HR=0.85[0.55-1.33]). A total of 338/623(54.2%) patients in “B” phenotype received corticosteroids. The CPH (HR =0.65 [0.46-0.91]) and TIR regression (1- 25 day tHR=0.56[0.39-0.82] and >25 days tHR=1.53[1.03-7.12]) showed a biphasic effect of corticosteroids due to proportional assumption violation. No effect of corticosteroids on ICU mortality was observed when WCR was performed (wHR=0.72[0.49-1.05]). Finally, 535/857(62.4%) patients in “C” phenotype received corticosteroids. The CPH (HR=0.73[0.63-0.98]) and TIR regression (1- 25 day tHR=0.69[ 0.53-0.89] and >25 days tHR=1.30[ 1.14-3.25]) showed a biphasic effect of corticosteroids and proportional assumption violation. However, wHR (0.75[0.58-0.98]) and sHR (0.79[0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. Conclusion: Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate-high dose. Only patients with the highest severity could benefit from steroid treatment although this effect on clinical outcome was minimized during ICU stay.

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Rapid Muscle Loss Negatively Impacts Survival in Critically Ill Patients With Cirrhosis

Journal of Intensive Care Medicine ◽

10.1177/0885066618775706 ◽

2018 ◽

Vol 35 (7) ◽

pp. 663-671 ◽

Cited By ~ 3

Author(s):

Sunmi Ju ◽

Sun Mi Choi ◽

Young Sik Park ◽

Chang-Hoon Lee ◽

Sang-Min Lee ◽

...

Keyword(s):

Hospital Mortality ◽

Critically Ill ◽

Muscle Mass ◽

Critically Ill Patients ◽

Mass Change ◽

Apache Ii Score ◽

Muscle Loss ◽

Icu Mortality ◽

Skeletal Muscle Index ◽

The Impact

Purpose: To assess the impact of rapid muscle loss before admission to intensive care unit (ICU) in critically ill patients with cirrhosis. Materials and Methods: Patients with cirrhosis who had undergone 2 or more recent computed tomography scans before admission to the medical ICU were included. Muscle cross-sectional area at the level of the third lumbar vertebra was quantified using OsiriX software. The rate of muscle mass change and skeletal muscle index (SMI) were also calculated. Multivariable Cox proportional hazards regression was used to evaluate the association between muscle loss and mortality. Results: Among 125 patients, 113 (90.4%) patients were classified as having sarcopenia. The mean body mass index was 22.6 (3.9) kg/m2. Thirty-nine (31.2%) patients were within the normal range for muscle mass change, while 86 (68.8%) patients demonstrated rapid decline in muscle mass before admission to the ICU. Patients with rapid muscle loss showed high ICU mortality (59.3%) and in-hospital mortality (77.9%). Multivariate Cox analysis showed that ICU mortality and in-hospital mortality were independently associated with malignancy, Acute Physiology and Chronic Health Evaluation (APACHE) II score, SMI, and rapid muscle loss. Conclusion: Rapid muscle decline is correlated with increased ICU mortality and in-hospital mortality in critically ill patients with cirrhosis.

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Early oseltamivir treatment improves survival in critically ill patients with influenza pneumonia

ERJ Open Research ◽

10.1183/23120541.00888-2020 ◽

2021 ◽

pp. 00888-2020

Author(s):

Gerard Moreno ◽

Alejandro Rodríguez ◽

Jordi Sole-Violán ◽

Ignacio Martín-Loeches ◽

Emili Díaz ◽

...

Keyword(s):

Length Of Stay ◽

Propensity Score ◽

Propensity Score Matching ◽

Critically Ill ◽

Critically Ill Patients ◽

Early Treatment ◽

Survival Rates ◽

Icu Mortality ◽

Icu Length Of Stay ◽

Influenza Pneumonia

Background and aimsThe relationship between early oseltamivir treatment (within 48 h of symptom onset) and mortality in patients admitted to intensive care units (ICUs) with severe influenza is disputed. This study aimed to investigate the association between early oseltamivir treatment and ICU mortality in critically ill patients with influenza pneumonia.MethodsThis was an observational study of patients with influenza pneumonia admitted to 184 ICUs in Spain. The primary outcome was to evaluate the association between early oseltamivir treatment and ICU mortality compared to later treatment. Secondary outcomes were to compare the duration of mechanical ventilation (MV) and the ICU length of stay between the early and later oseltamivir treatment groups. To reduce biases related to observational studies, propensity score matching and a competing risk analysis were performed.ResultsDuring the study period, 2124 met the inclusion criteria. All patients had influenza pneumonia and received oseltamivir before ICU admission. Of these, 529 (24.9%) received early oseltamivir treatment. In the multivariate analysis, early treatment was associated with reduced ICU mortality (OR 0.69, 95% CI 0.51–0.95). After propensity score matching, early oseltamivir treatment was associated with improved survival rates in the Cox regression (HR 0.77, 95% CI 0.61–0.99) and competing risk (sHR 0.67, 95% CI 0.53–0.85) analyses. The ICU length of stay and duration of MV were shorter in patients receiving early treatment.ConclusionsEarly oseltamivir treatment is associated with improved survival rates in critically ill patients with influenza pneumonia and may decrease ICU length of stay and MV duration.

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Mechanical Power Normalized to Predicted Body Weight is Associated with Mortality in Critically Ill Patients: A Cohort Study

10.21203/rs.3.rs-534242/v1 ◽

2021 ◽

Author(s):

Yanhong Zhu ◽

Wenyong Peng ◽

Shuai Zhen ◽

Xiaofeng Jiang

Keyword(s):

Body Weight ◽

Length Of Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Critical Factor ◽

Mechanical Power ◽

Invasive Ventilation ◽

Icu Mortality ◽

Predicted Body Weight ◽

Icu Length Of Stay

Abstract Background: Mechanical power (MP), defined as the amount of energy produced by mechanical ventilation and released into the respiratory system, has long been considered a critical factor in the pathogenesis of ventilator-induced lung injury. However, our knowledge suggests that the effects of MP may be proportional to their involvement in total lung function size. Therefore, MP normalized to predicted body weight (norMP) should be greater than absolute MP value. The objective of this research is to determine the connection between norMP and mortality in critically ill patients who have been on invasive ventilation for at least 48 hours.Methods: This is a study of data stored in the databases of the MIMIC–III, which contains data of critically ill patients for over 50,000. The study involved critically ill patients who had been on invasive ventilation for at least 48 hours. norMP was the relevant exposure. The major endpoint was ICU mortality, the secondary endpoints were 30-day, 90-day mortality; ICU length of stay, the number of ventilator-free days at day 28.Result: The study involved a total of 1301 critically ill patients. This study revealed that norMP was correlated with ICU mortality [OR per quartile increase 1.20 (95% CI 1.07–1.35), p = 0.009]. Similarly, norMP was correlated with ventilator-free days at day 28, ICU length of stay. In the subgroup analysis, high norMP was associated with ICU mortality whether low or high Vt (OR 1.22, 95% CI 1.01–1.47, p = 0.040; OR 1.28, 95% CI 1.06–1.54, p = 0.011, respectively). But high norMP was associated with ICU mortality only in low PIP (OR 1.18, 95% CI 1.01–1.37, p = 0.034)Conclusion: Our findings indicate that higher norMP is independently linked with elevated ICU mortality and various other clinical findings in critically ill patients with a minimum of 48 hours of invasive ventilation.

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Mechanical power normalized to predicted body weight is associated with mortality in critically ill patients: a cohort study

BMC Anesthesiology ◽

10.1186/s12871-021-01497-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Yanhong Zhu ◽

Wenyong Peng ◽

Shuai Zhen ◽

Xiaofeng Jiang

Keyword(s):

Body Weight ◽

Length Of Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Clinical Findings ◽

Mechanical Power ◽

Invasive Ventilation ◽

Icu Mortality ◽

Predicted Body Weight ◽

Icu Length Of Stay

Abstract Background Mechanical power (MP), defined as the amount of energy produced by mechanical ventilation and released into the respiratory system, was reportedly a determining factor in the pathogenesis of ventilator-induced lung injury. However, previous studies suggest that the effects of MP were proportional to their involvement in the total lung function size. Therefore, MP normalized to the predicted body weight (norMP) should outperform the absolute MP value. The objective of this research is to determine the connection between norMP and mortality in critically ill patients who have been on invasive ventilation for at least 48 h. Methods This is a study of data stored in the databases of the MIMIC–III, which contains data of critically ill patients for over 50,000. The study involved critically ill patients who had been on invasive ventilation for at least 48 h. norMP was the relevant exposure. The major endpoint was ICU mortality, the secondary endpoints were 30-day, 90-day mortality; ICU length of stay, the number of ventilator-free days at day 28. Result The study involved a total of 1301 critically ill patients. This study revealed that norMP was correlated with ICU mortality [OR per quartile increase 1.33 (95% CI 1.16–1.52), p < 0.001]. Similarly, norMP was correlated with ventilator-free days at day 28, ICU length of stay. In the subgroup analysis, high norMP was associated with ICU mortality whether low or high Vt (OR 1.31, 95% CI 1.09–1.57, p = 0.004; OR 1.32, 95% CI 1.08–1.62, p = 0.008, respectively). But high norMP was associated with ICU mortality only in low PIP (OR 1.18, 95% CI 1.01–1.38, p = 0.034). Conclusion Our findings indicate that higher norMP is independently linked with elevated ICU mortality and various other clinical findings in critically ill patients with a minimum of 48 h of invasive ventilation.

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Point-of-Care Ultrasound-Guided Conservative Fluid Therapy Improved the Outcome of Critically Ill Patients: A Before-and-After Study

10.21203/rs.3.rs-133531/v2 ◽

2021 ◽

Author(s):

Hui He ◽

Mingqiang Zeng ◽

Jing Chen ◽

Lei Deng ◽

Youdai Chen

Keyword(s):

Critically Ill ◽

Fluid Balance ◽

Critically Ill Patients ◽

Point Of Care ◽

Apache Ii Score ◽

Point Of Care Ultrasound ◽

Icu Mortality ◽

Icu Stay ◽

The Impact ◽

Cumulative Fluid Balance

Abstract ObjectivesTo study the impact of fluid balance on the outcome of critically ill patients.MethodsCritically ill patients managed with point-of-care ultrasound were compared with those managed without. Distended internal jugular veins and inferior vena cava with reduced collapsibility were taken as signs of hypervolemia.ResultsCompared with critically ill patients admitted before application of point-of-care ultrasound assessment (from March, 2019 through October, 2019; 291 cases), cases admitted after (from November, 2019 through June, 2020; 285 cases) had significantly lower in-ICU mortality (34.7% vs 26.7%, p=0.038; Fisher’s exact test), together with a dramatic change from overall positive fluid balance to negative one (for cumulative fluid balance during ICU stay, 2820±1381ml vs -10±39ml; p=0.001). Multiple logistic regression showed that cumulative fluid balance during ICU stay, Acute Physiology and Chronic Health Evaluation (APACHE) II score and Sequential Organ Failure Assessment (SOFA) score on admission were independent risk factors for in-ICU mortality (p<0.001, p<0.001 and p=0.043 respectively). After controlling for disease severity, Cox hazard ratio of cases with a negative cumulative fluid balance during ICU stay was 0.683 (95% confidence interval 0.475-0.981; p=0039).ConclusionsNegative cumulative fluid balance during ICU stay was associated with a reduced in-ICU mortality.

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Evaluation of Delirium in Critically Ill Patients Prescribed Melatonin or Ramelteon

Annals of Pharmacotherapy ◽

10.1177/10600280211002054 ◽

2021 ◽

pp. 106002802110020

Author(s):

Natasha Romero ◽

Kevin M. Dube ◽

Kenneth E. Lupi ◽

Jeremy R. DeGrado

Keyword(s):

Clinical Outcomes ◽

Critically Ill ◽

Critically Ill Patients ◽

Receptor Agonist ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Melatonin Receptor ◽

Observational Cohort ◽

Impaired Sleep ◽

Retrospective Observational Cohort Study

Background: An impaired sleep-wake cycle may be one factor that affects the development of delirium in critically ill patients. Several small studies suggest that exogenous melatonin or ramelteon may decrease the incidence and/or duration of delirium. Objective: To compare the effect of prophylactic administration of melatonin, ramelteon, or no melatonin receptor agonist on the development of delirium in the intensive care unit (ICU). Methods: This was a single-center, retrospective, observational cohort study of nondelirious patients in the ICU who received melatonin, ramelteon, or no melatonin receptor agonist. The primary end point was the incidence of delirium. Secondary end points included assessments of daily level of sedation and daily utilization of antipsychotic, sedative, and opioid agents. Results: No difference was observed in the incidence of delirium among the melatonin, ramelteon, and placebo cohorts (18.7% vs 14.3% vs 13.8%; P = 0.77). A difference was observed in the rate of agitation and sedation among the 3 groups, with the greatest observed in the melatonin cohort. Additionally, there was a difference in the use of propofol, dexmedetomidine, and opioids. Overall, there was no difference in clinical outcomes, including duration of mechanical ventilation and ICU or hospital length of stay. Conclusion and Relevance: Therapy with melatonin, ramelteon, and no melatonin receptor agonist resulted in similar rates of delirium in a mixed ICU population. Despite significant differences in agitation, sedation, and medication utilization, there was no differences in the clinical outcomes evaluated.

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