scholarly journals Emergency Laparotomy in the Critically Ill: Futility at the Bedside

2018 ◽  
Vol 2018 ◽  
pp. 1-6 ◽  
Author(s):  
Niels D. Martin ◽  
Sagar P. Patel ◽  
Kristen Chreiman ◽  
Jose L. Pascual ◽  
Benjamin Braslow ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Critically Ill ◽  
High Mortality ◽  
Kidney Injury ◽  
Acute Care Surgery ◽  
Emergency Laparotomy ◽  
Abdominal Exploration ◽  
Lactate Levels ◽  
American Society ◽  
Care Surgery

Background. Critically ill patients are often evaluated for an intra-abdominal catastrophe. In the absence of a preoperative diagnosis, abdominal exploration may be offered despite desperate circumstances. We hypothesize that (1) abdominal exploration for such patients is associated with a high mortality and (2) commonly obtained physiologic measures at laparotomy anticipate mortality. Methods. All acute care surgery (ACS) patients undergoing emergency laparotomy at a quaternary referral center during a 3-year period were reviewed. Inclusion was defined by emergency laparotomy in the operating room (OR) in a patient with an American Society of Anesthesiologists (ASA) score ≥4 or bedside laparotomy in the ICU (BSL). Mortality was the primary endpoint and was stratified by demographics, admitting service, surgical findings, and physiology. Comparisons between OR and BSL were by Fisher’s exact and Mann–Whitney tests. Results. 144 patients underwent emergency laparotomy (45 BSL vs. 99 OR). Overall mortality was 55.6% (77.8% BSL vs. 45.5% OR; p<0.001). Mortality by admitting service was cardiac 71.4% (n=42), medical 70% (n=30), ACS 42% (n=50), and other 36.4% (n=22) services. Preoperative lactate levels were higher in nonsurvivors (2.7 vs. 8.5 mmol/L, p<0.001), as was vasopressor use (62.5% vs. 97.5%, p<0.001), acute kidney injury (51.6% vs. 72.5%, p<0.01), leukocytosis (53.1% vs. 71.3%, p<0.04), and anemia (45.3% vs. 71.3%, p<0.01). The presence of any identifiable abdominal pathology established a 90% mortality rate. Conclusions. The need for BSL portends an extremely high mortality rate and is likely useful in preintervention counselling. Emergency OR laparotomy leads to mortality in nearly half of such patients and is anticipatable based on concurrent abnormal physiology.

scholarly journals Prognostic impact of elevated lactate levels on mortality in critically ill patients with and without preadmission metformin treatment: a Danish registry-based cohort study

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Rene A. Posma ◽  
Trine Frøslev ◽  
Bente Jespersen ◽  
Iwan C. C. van der Horst ◽  
Daan J. Touw ◽  
...  
Keyword(s):  
Cohort Study ◽  
Mortality Rate ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Cox Regression ◽  
Lower Mortality ◽  
Prognostic Impact ◽  
Icu Admission ◽  
Lactate Levels ◽  
Restricted Cubic Splines

Abstract Background Lactate is a robust prognostic marker for the outcome of critically ill patients. Several small studies reported that metformin users have higher lactate levels at ICU admission without a concomitant increase in mortality. However, this has not been investigated in a larger cohort. We aimed to determine whether the association between lactate levels around ICU admission and mortality is different in metformin users compared to metformin nonusers. Methods This cohort study included patients admitted to ICUs in northern Denmark between January 2010 and August 2017 with any circulating lactate measured around ICU admission, which was defined as 12 h before until 6 h after admission. The association between the mean of the lactate levels measured during this period and 30-day mortality was determined for metformin users and nonusers by modelling restricted cubic splines obtained from a Cox regression model. Results Of 37,293 included patients, 3183 (9%) used metformin. The median (interquartile range) lactate level was 1.8 (1.2–3.2) in metformin users and 1.6 (1.0–2.7) mmol/L in metformin nonusers. Lactate levels were strongly associated with mortality for both metformin users and nonusers. However, the association of lactate with mortality was different for metformin users, with a lower mortality rate in metformin users than in nonusers when admitted with similar lactate levels. This was observed over the whole range of lactate levels, and consequently, the relation of lactate with mortality was shifted rightwards for metformin users. Conclusion In this large observational cohort of critically ill patients, early lactate levels were strongly associated with mortality. Irrespective of the degree of hyperlactataemia, similar lactate levels were associated with a lower mortality rate in metformin users compared with metformin nonusers. Therefore, lactate levels around ICU admission should be interpreted according to metformin use.

scholarly journals Bowel necrosis in patient with severe case of COVID-19: a case report

BMC Surgery ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Daniel Ardian Soeselo ◽  
Wirawan Hambali ◽  
Sandy Theresia
Keyword(s):  
Case Report ◽  
Mortality Rate ◽  
Critically Ill ◽  
High Mortality ◽  
Severe Case ◽  
Bowel Necrosis ◽  
Case Presentation ◽  
Gastrointestinal Manifestations ◽  
Emergent Laparotomy

Abstract Background In patients who are critically ill with COVID-19, multiple extrapulmonary manifestations of the disease have been observed, including gastrointestinal manifestations. Case presentation We present a case of a 65 year old man with severe COVID-19 pneumonia that developed hypercoagulation and peritonitis. Emergent laparotomy was performed and we found bowel necrosis in two sites. Conclusions Although rare, the presentation of COVID-19 with bowel necrosis requires emergency treatments, and it has high mortality rate.

Which dialysis method should be used for patients with COVID-19?

2020 ◽  
Vol 54 ◽  
Author(s):  
Patricia Maria Gregoria Mina-Cuaño ◽  
Cary Amiel G. Villanueva ◽  
John Jefferson V. Besa ◽  
Andrew Rufino M. Villafuerte ◽  
Jayson M. Villavicencio ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Invasive Mechanical Ventilation ◽  
Kidney Injury ◽  
Control Measures ◽  
Intermittent Hemodialysis ◽  
Strict Adherence ◽  
Infection Control Measures ◽  
Dialysis Method ◽  
American Society

KEY FINDINGS• Very low-quality evidence from a single retrospective study suggests that continuous renal replacementtherapy (CRRT) may reduce mortality among COVID-19 patients on invasive mechanical ventilation. Guidelinesrecommend CRRT for critically ill patients to minimize the risk of possible transmission, if this option is available.• Although uncommon, acute kidney injury (AKI) can occur in association with coronavirus disease 2019(COVID-19) and is associated with increased in-hospital mortality.• There are currently no published or ongoing clinical trials directly comparing dialysis modalities for acutekidney injury in COVID-19 patients.• In reducing the risk of transmission during dialysis: currently, there are no studies comparing one dialysismodality to another. The method of dialysis is still primarily determined by the clinical picture of the patient, theexpertise of the center, and the resources available. The American Society of Nephrology (ASN) recommendsCRRT over intermittent hemodialysis (IHD) for critically ill patients with COVID-19 to minimize patient contactwhen it is available, and resources allow. Otherwise, intermittent hemodialysis may be done provided that,infection control measures are strictly followed.• Several international and local guidelines recommend strict adherence to infection prevention and controlmeasures (e.g. hand hygiene, physical distancing, proper use of personal protective equipment (PPE), andcohorting of patients) who are undergoing dialysis.

scholarly journals Clinical characteristics and predictors of mortality in critically ill influenza adult patients

2020 ◽  
Author(s):  
Jui-Chi Hsu ◽  
Ing-Kit Lee ◽  
Wen-Chi Huang ◽  
Yi-Chun Chen ◽  
Ching-Yen Tsai
Keyword(s):  
Acute Kidney Injury ◽  
Gastrointestinal Bleeding ◽  
Critically Ill ◽  
Kidney Injury ◽  
Adult Patients ◽  
Chang Gung Memorial Hospital ◽  
High Morbidity ◽  
Predictive Tool ◽  
Predictors Of Mortality ◽  
Lactate Levels

Abstract Background Severe influenza is associated with high morbidity and mortality. The aim of this study was to investigate the factors affecting the clinical outcomes of critically ill influenza patients. Methods In this retrospective study, we enrolled critically ill adult patients with influenza at the Kaohsiung Chang Gung Memorial Hospital in Taiwan. We evaluated the demographic, clinical, and laboratory findings and examined whether any of these measurements correlated with mortality. We then created an event-based algorithm as a simple predictive tool using 2 variables with statistically significant associations with mortality. Results Between 2015 and 2018, 102 critically ill influenza patients (median age, 62 years) were assessed; among them, 41 (40.1%) patients died. Of the 94 patients who received oseltamivir therapy, 68 (72.3%) began taking oseltamivir 48 hours after the onset of illness. Of the 102 patients, the major influenza-associated complications were respiratory failure (97%), pneumonia (94.1%), acute kidney injury (65.7%), adult respiratory distress syndrome (ARDS) (51%), gastrointestinal bleeding (35.3%), and bacteremia (16.7%). In the multivariate regression model, high lactate levels, ARDS, acute kidney injury, and gastrointestinal bleeding were independent predictors of mortality in critically ill influenza patients. The optimal lactate level cutoff for predicting mortality was 33 mg/dL with an area under curve of 0.728. We constructed an event-associated algorithm that included lactate and ARDS. Fifteen (75%) of 20 patients with lactate levels ≥33 mg/dL and ARDS died, compared with only 1 (7.7%) of 13 patients with normal lactate levels and without ARDS. Conclusions We identified clinical and laboratory predictors of mortality at hospital admission that could aid in the care of critically ill influenza patients. Identification of these prognostic markers could be improved to prioritize key examinations that might be useful in determining patient outcomes.

scholarly journals Characteristics of Invasive Fungal Infections among HIV Individuals from an Indigenous Origin in Mexico

2018 ◽  
Vol 4 (3) ◽  
pp. 109
Author(s):  
Mercedes Aranda-Audelo ◽  
Norma Rivera-Martínez ◽  
Dora Corzo-León
Keyword(s):  
Acute Kidney Injury ◽  
T Cells ◽  
Retrospective Study ◽  
Mortality Rate ◽  
High Mortality ◽  
Fungal Infections ◽  
Kidney Injury ◽  
Invasive Fungal Infections ◽  
Atypical Pneumonia ◽  
Hiv Aids

In individuals with HIV/AIDS, 47% of the deaths are attributed to invasive fungal infections (IFIs), despite antiretroviral (ARV) therapy. This is a retrospective study carried out in the Hospital Regional de Alta Especialidad Oaxaca (HRAEO), southwest Mexico, where IFIs that occurred during 2016–2017 are described. A total of 55 individuals were included. Histoplasmosis (36%) and possible-IFIs in neutropenic fever (20%) were the most frequent cases, followed by cryptococcosis (14%). The HIV/AIDS subpopulation corresponded with 26 cases (47%), all from an indigenous origin. The incidence of IFIs among them was 24% (95% CI = 15–33%). The CD4+ T cells median was 35 cells/mL (IQR 12–58). Four cases (15%) of unmasking IRIS were identified, three of histoplasmosis and one coccidioidomycosis. Co-infections were found in 52% (12/23), and tuberculosis in 50% (6/12) was the most frequent. The mortality rate was 48%. The general characteristics of the HIV individuals who died were atypical pneumonia (70% vs. 9%, p = 0.01), acute kidney injury, (70% vs. 9%, p = 0.008) and ICU stay (80% vs. 9%, p = 0.002). In conclusion, IFIs are diagnosed in one out of four individuals with HIV/AIDS along with other complicated infectious conditions, leading to major complications and a high mortality rate.

scholarly journals Acute kidney injury and mortality in critically ill children

2014 ◽  
Vol 54 (5) ◽  
pp. 251
Author(s):  
Putri Amelia ◽  
Munar Lubis ◽  
Ema Mutiara ◽  
Yunnie Trisnawati
Keyword(s):  
Acute Kidney Injury ◽  
Mortality Rate ◽  
Critically Ill ◽  
Organ Dysfunction ◽  
Kidney Injury ◽  
Cross Sectional Study ◽  
Critically Ill Children ◽  
Cross Sectional ◽  
Logistic Organ Dysfunction ◽  
Stage Renal Disease

Background Mortality from acute kidney injury (AKI) can be ashigh as 60% in critically ill children. This high mortality rate isinfluenced by the severity of primary diseases, organ dysfunction,and the stage of acute kidney injury.Objective To assess for an as sedation between AKI and mortalityin critically ill children hospitalized in the pediatric intensive careunit (PICU).Methods A cross-sectional study was conducted from Aprilto July 2012. All patients aged 1 month to 18 years who werehospitalized in the PICU for more than 24 hours were included.Urine output and serum creatinine levels were evaluated daily.Patients were categorized according to the pediatric risk, injury,failure, loss, and end stage renal disease (pRIFLE) criteria. Chisquare, Fisher's exact, Mann-\X'hitney U, and Kruskal-Wallis testswere used to assess for an association between AKI, mortality,pediatric logistic organ dysfunction (PELOD) score, and lengthof PICU stay. AP value of < 0.05 was considered as statisticallysignificant.Results During the study period, 57 children were admitted,consisting of 25 (43.9%) females and 32 (56.1 %) males, witha median age of 43 months. The prevalance of AKI was 31.5%(18/57) and classified into stages: risk 13/18, injury 3/18, andfailure 2/18. The mortality rate for AKI was 16. 7%. There was noassociation between AKI and mortality (P=0.592). The PELODscores were found to be similar among patients (SD 11.3 2 vs. SD12.23; P=0.830), and there was no association between AKI andlength of PICU stay (P=0.819).Conclusion There is no association between AKI and mortalityin critically ill children admitted in PICU.

scholarly journals Bowel Necrosis in Patient with Severe Case of COVID-19: A Case Report

2020 ◽  
Author(s):  
Daniel Ardian Soeselo ◽  
Sandy Theresia ◽  
Wirawan Hambali
Keyword(s):  
Case Report ◽  
Mortality Rate ◽  
Critically Ill ◽  
High Mortality ◽  
Severe Case ◽  
Bowel Necrosis ◽  
Case Presentation ◽  
Gastrointestinal Manifestations ◽  
Emergent Laparotomy

Abstract Background: In patients who are critically ill with COVID-19, multiple extrapulmonary manifestations of the disease have been observed, including gastrointestinal manifestations. Case Presentation: We present a case of a 65 year old man with severe COVID-19 pneumonia that developed hypercoagulation and peritonitis. Emergent laparotomy was performed and we found bowel necrosis in two sites. Conclusions: Although rare, the presentation of COVID-19 with bowel necrosis requires emergency treatments, and it has high mortality rate.

scholarly journals Clinical Characteristics and Predictors of Mortality in Critically Ill Influenza Adult Patients

2020 ◽  
Vol 9 (4) ◽  
pp. 1073
Author(s):  
Jui-Chi Hsu ◽  
Ing-Kit Lee ◽  
Wen-Chi Huang ◽  
Yi-Chun Chen ◽  
Ching-Yen Tsai
Keyword(s):  
Acute Kidney Injury ◽  
Gastrointestinal Bleeding ◽  
Critically Ill ◽  
Kidney Injury ◽  
Adult Patients ◽  
Chang Gung Memorial Hospital ◽  
High Morbidity ◽  
Predictive Tool ◽  
Predictors Of Mortality ◽  
Lactate Levels

Severe influenza is associated with high morbidity and mortality. The aim of this study was to investigate the factors affecting the clinical outcomes of critically ill influenza patients. In this retrospective study, we enrolled critically ill adult patients with influenza at the Kaohsiung Chang Gung Memorial Hospital in Taiwan. We evaluated the demographic, clinical, and laboratory findings and examined whether any of these measurements correlated with mortality. We then created an event-based algorithm as a simple predictive tool using two variables with statistically significant associations with mortality. Between 2015 and 2018, 102 critically ill influenza patients (median age, 62 years) were assessed; among them, 41 (40.1%) patients died. Of the 94 patients who received oseltamivir therapy, 68 (72.3%) began taking oseltamivir 48 h after the onset of illness. Of the 102 patients, the major influenza-associated complications were respiratory failure (97%), pneumonia (94.1%), acute kidney injury (65.7%), adult respiratory distress syndrome (ARDS) (51%), gastrointestinal bleeding (35.3%), and bacteremia (16.7%). In the multivariate regression model, high lactate levels, ARDS, acute kidney injury, and gastrointestinal bleeding were independent predictors of mortality in critically ill influenza patients. The optimal lactate level cutoff for predicting mortality was 3.7 mmol/L with an area under curve of 0.728. We constructed an event-associated algorithm that included lactate and ARDS. Fifteen (75%) of 20 patients with lactate levels 3.7 mmol/L and ARDS died, compared with only 1 (7.7%) of 13 patients with normal lactate levels and without ARDS. We identified clinical and laboratory predictors of mortality that could aid in the care of critically ill influenza patients. Identification of these prognostic markers could be improved to prioritize key examinations that might be useful in determining patient outcomes.

scholarly journals Prescribing Habits of Providers and Risk Factors for Nonadherence to Opioid Prescribing Guidelines

2020 ◽  
pp. 000313482095633
Author(s):  
Tommy Ivanics ◽  
Hassan Nasser ◽  
Pridvi Kandagatla ◽  
Shravan Leonard-Murali ◽  
Adam Jones ◽  
...  
Keyword(s):  
Risk Factors ◽  
Guideline Implementation ◽  
Multivariable Analysis ◽  
Acute Care Surgery ◽  
Factors Associated ◽  
Opioid Prescribing ◽  
Academic Center ◽  
American Society ◽  
Care Surgery ◽  
American Society Of Anesthesiologists

Background The Michigan Opioid Prescribing Engagement Network introduced guidelines in October 2017 to combat opioid overprescription following various surgical procedures. We sought to evaluate changes in opioid prescribing at our academic center and identify factors associated with nonadherence to recently implemented opioid prescribing guidelines. Methods This retrospective review analyzed opioid prescribing data for appendectomy, cholecystectomy, and hernia repair from January 2015 through September 2017 (pre-guidelines group) and November 2017 through December 2018 (post-guidelines group). October 2017 data were excluded to allow for guideline implementation. Opioid prescribing data were recorded as total morphine equivalents (TMEs). Results Of 1493 cases (903 pre-vs. 590 post-guidelines), the mean TME prescribed significantly decreased post-guidelines (231.9 ± 108.6 vs. 112.7 ± 73.9 mg; P < .01). More providers prescribed within recommended limits post-guidelines (2.8% vs. 44.8%; P < .01). On multivariable analysis, independent risk factors for guideline nonadherence were the American Society of Anesthesiologists class > 2 (adjusted odds ratio [AOR]:1.65, 95% confidence interval[CI] 1.09-2.49; P = .02), general surgery vs. acute care surgery service (AOR 1.89, 95% CI 1.15-3.10; P = .01), oxycodone vs. hydrocodone (AOR:1.90, 95% CI:1.06-3.41; P = .03), and nonphysician provider vs. resident prescriber (AOR:2.10, 95% CI:1.14-3.11; P < .01). Conclusions Opioid prescribing significantly reduced after the adoption of opioid prescribing guidelines at our institution. Numerous factors associated with provider guideline nonadherence may identify actionable targets to minimize opioid overprescribing further.

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