scholarly journals Circulating bioactive adrenomedullin as a marker of sepsis, septic shock and critical illness

Critical Care ◽  
2020 ◽  
Vol 24 (1) ◽  
Author(s):  
Oscar H. M. Lundberg ◽  
Maria Lengquist ◽  
Martin Spångfors ◽  
Martin Annborn ◽  
Deborah Bergmann ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Septic Shock ◽  
Critical Illness ◽  
Organ Failure ◽  
Primary Outcome ◽  
Organ Support ◽  
Severity Of Disease ◽  
Therapeutic Value ◽  
Secondary Outcomes ◽  
Youden’S Index

Abstract Background Biomarkers can be of help to understand critical illness and to identify and stratify sepsis. Adrenomedullin is a vasoactive hormone, with reported prognostic and potentially therapeutic value in sepsis. The primary aim of this study was to investigate the association of circulating bioactive adrenomedullin (bio-ADM) levels at intensive care unit (ICU) admission with mortality in sepsis patients and in a general ICU population. Secondary aims included the association of bio-ADM with organ failure and the ability of bio-ADM to identify sepsis. Methods In this retrospective observational study, adult patients admitted to one of four ICUs during 2016 had admission bio-ADM levels analysed. Age-adjusted odds ratios (OR) with 95% CI for log-2 transformed bio-ADM, and Youden’s index derived cut-offs were calculated. The primary outcome was 30-day mortality, and secondary outcomes included the need for organ support and the ability to identify sepsis. Results Bio-ADM in 1867 consecutive patients were analysed; 632 patients fulfilled the sepsis-3 criteria of whom 267 had septic shock. The median bio-ADM in the entire ICU population was 40 pg/mL, 74 pg/mL in sepsis patients, 107 pg/mL in septic shock and 29 pg/mL in non-septic patients. The association of elevated bio-ADM and mortality in sepsis patients and the ICU population resulted in ORs of 1.23 (95% CI 1.07–1.41) and 1.22 (95% CI 1.12–1.32), respectively. The association with mortality remained after additional adjustment for lactate in sepsis patients. Elevated bio-ADM was associated with an increased need for dialysis with ORs of 2.28 (95% CI 2.01–2.59) and 1.97 (95% CI 1.64–2.36) for the ICU population and sepsis patients, respectively, and with increased need of vasopressors, OR 1.33 (95% CI 1.23–1.42) (95% CI 1.17–1.50) for both populations. Sepsis was identified with an OR of 1.78 (95% CI 1.64–1.94) for bio-ADM, after additional adjustment for severity of disease. A bio-ADM cut-off of 70 pg/mL differentiated between survivors and non-survivors in sepsis, but a Youden’s index derived threshold of 108 pg/mL performed better. Conclusions Admission bio-ADM is associated with 30-day mortality and organ failure in sepsis patients as well as in a general ICU population. Bio-ADM may be a morbidity-independent sepsis biomarker.

scholarly journals Intensive Care Unit Capacity Strain and Outcomes of Critical Illness in a Resource-Limited Setting: A 2-Hospital Study in South Africa

2018 ◽  
Vol 35 (10) ◽  
pp. 1104-1111 ◽  
Author(s):  
George L. Anesi ◽  
Nicole B. Gabler ◽  
Nikki L. Allorto ◽  
Carel Cairns ◽  
Gary E. Weissman ◽  
...  
Keyword(s):  
South Africa ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Critical Illness ◽  
Primary Outcome ◽  
Resource Limited Setting ◽  
Icu Mortality ◽  
Icu Admission ◽  
Resource Limited ◽  
Limited Setting

Objective: To measure the association of intensive care unit (ICU) capacity strain with processes of care and outcomes of critical illness in a resource-limited setting. Methods: We performed a retrospective cohort study of 5332 patients referred to the ICUs at 2 public hospitals in South Africa using the country’s first published multicenter electronic critical care database. We assessed the association between multiple ICU capacity strain metrics (ICU occupancy, turnover, census acuity, and referral burden) at different exposure time points (ICU referral, admission, and/or discharge) with clinical and process of care outcomes. The association of ICU capacity strain at the time of ICU admission with ICU length of stay (LOS), the primary outcome, was analyzed with a multivariable Cox proportional hazard model. Secondary outcomes of ICU triage decision (with strain at ICU referral), ICU mortality (with strain at ICU admission), and ICU LOS (with strain at ICU discharge), were analyzed with linear and logistic multivariable regression. Results: No measure of ICU capacity strain at the time of ICU admission was associated with ICU LOS, the primary outcome. The ICU occupancy at the time of ICU admission was associated with increased odds of ICU mortality (odds ratio = 1.07, 95% confidence interval: 1.02-1.11; P = .004), a secondary outcome, such that a 10% increase in ICU occupancy would be associated with a 7% increase in the odds of ICU mortality. Conclusions: In a resource-limited setting in South Africa, ICU capacity strain at the time of ICU admission was not associated with ICU LOS. In secondary analyses, higher ICU occupancy at the time of ICU admission, but not other measures of capacity strain, was associated with increased odds of ICU mortality.

Evaluation of qSOFA as a Predictor of Mortality Among ICU Patients With Positive Clinical Cultures—A Retrospective Cohort Study

2019 ◽  
Vol 35 (11) ◽  
pp. 1278-1284
Author(s):  
Barry Kelly ◽  
Johann Patlak ◽  
Shahzad Shaefi ◽  
Dustin Boone ◽  
Ariel Mueller ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Sequential Organ Failure Assessment ◽  
Organ Failure ◽  
Retrospective Cohort ◽  
Primary Outcome ◽  
Assessment Score ◽  
Failure Assessment ◽  
Discriminative Value

Objective: To compare the discriminative value of the quick-sequential organ failure assessment score (qSOFA) to SOFA in a critically ill population, in which a microbial pathogen was isolated within 48 hours of admission to intensive care. Design: Retrospective cohort study. Setting: Academic tertiary referral center from July 2008 to June 2017. Patients: Hospitalized patients admitted to intensive care unit. Interventions: None. Measurements and Main Results: The primary outcome was in-hospital mortality for all patients with confirmed positive microbiological cultures within 48 hours of admission to intensive care unit (ICU). Subgroup analysis was performed on patients with pathogenic bacteremia or positive cultures in cerebrospinal fluid. Of the 11 415 patients analyzed with positive microbiology specimens within 48 hours of admission, 2933 (25.7%) had a qSOFA ≥2. Of these, 16.6% reached the primary outcome of in-hospital mortality. Unsurprisingly, the discriminative value of qSOFA on admission was significantly worse than that of SOFA (0.73 vs 0.76; P = .0004), despite observing a significant association between qSOFA category and in-hospital mortality ( P < .0001). In secondary analyses, similar observations were found using qSOFA within 6 and 24 hours of ICU admission. When analysis was focused on patients with pathogenic bacteremia or positive cerebrospinal fluid (CSF) cultures (n = 1646), there was no significant difference between the discriminative value of qSOFA and SOFA (0.75 vs 0.78; P = .17). Conclusions: Quick-sequential organ failure assessment score at admission was not superior to SOFA in predicting in-hospital mortality in patients with positive clinical cultures within 48 hours of admission to ICU. Quick-sequential organ failure assessment score at admission to the ICU was associated with mortality and showed reasonable calibration and discrimination. When the analysis was focused on patients with pathogenic bacteremia or positive CSF cultures, qSOFA performed similarly to SOFA in discriminatory those who will die from sepsis.

Hemodynamic Instability Secondary to Vasopressin Withdrawal in Septic Shock

2017 ◽  
Vol 34 (9) ◽  
pp. 761-765 ◽  
Author(s):  
Brittany D. Bissell ◽  
Carolyn Magee ◽  
Peter Moran ◽  
Melissa L. Thompson Bastin ◽  
Alexander H. Flannery
Keyword(s):  
Septic Shock ◽  
Primary Outcome ◽  
Hemodynamic Instability ◽  
Bolus Administration ◽  
Optimal Sequence ◽  
Norepinephrine Infusion ◽  
Increased Risk ◽  
Medical Intensive Care ◽  
Baseline Characteristics ◽  
Secondary Outcomes

Rationale: Vasopressors such as norepinephrine are first line for support of mean arterial pressure (MAP) in the management of septic shock. Their use, however, is commonly associated with many adverse events. These detriments frequently trigger the use of alternative, noncatecholamine therapies, including vasopressin. Vasopressin deficiency is a known physiologic consequence of septic shock, and while guidelines recommend vasopressin in addition to norepinephrine, no consensus exists on the duration of deficiency or ideal time of cessation. Studies have suggested that vasopressin discontinuation prior to other vasopressors may lead to hypotension; however, data are limited. This study evaluates the optimal sequence for the discontinuation of vasopressin therapy in septic shock. Methods: This was a 1-year retrospective study of 152 patients admitted to the medical intensive care unit (ICU) with septic shock who received concurrent norepinephrine and vasopressin for vasoactive support. Patients were excluded if death occurred on vasopressors, within 24 hours after discontinuation of vasopressors, or within 48 hours of ICU admission. The primary outcome of hemodynamic instability included incidence of hypotension after vasopressor discontinuation (2 consecutive MAPs < 60 mm Hg), fluid bolus administration, greater than 0.05 μg/kg/min increase in norepinephrine requirements, or addition of an alternative vasopressor. Secondary outcomes included time to hypotension, total vasopressor duration, arrhythmias, mortality, and length of stay. Results: Ninety-one patients met exclusion criteria, resulting in 61 patients for evaluation. Vasopressin was the first vasoactive therapy to be discontinued in 19 patients and last in 42 patients. Baseline characteristics and the use of potentially confounding treatments known to effect MAP were similar between groups. Discontinuation of vasopressin first was associated with a significant increase in hemodynamic instability (74% vs 16.7%, P < .01), with a shorter time to hemodynamic instability (5 vs 15 hours, P < .01). Secondary outcomes were similar. Conclusion: Vasopressin discontinuation prior to cessation of norepinephrine infusion was associated with an increased risk of hemodynamic instability.

Role of the intensive care unit

2018 ◽  
Author(s):  
Matt Wise ◽  
Paul Frost
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Organ Failure ◽  
Radiology Department ◽  
Organ Support ◽  
Specific Patient ◽  
High Dependency ◽  
Operating Theatres ◽  
The Uk ◽  
General Wards

The intensive care unit (ICU) can be defined as an area reserved for patients with potential or established organ failure and has the facilities for the diagnosis, prevention, and treatment of multi-organ failure. Usually, the ICU is located in close proximity to A & E, the radiology department, and the operating theatres, as it is between these areas that patient flows are greatest. In large urban hospitals, there may be more than one ICU, some of which serve specific patient populations, such as paediatrics, neurosurgery, cardiothoracic surgery, liver failure, and burns. Many hospitals also have high-dependency units (HDUs) that offer higher nurse-to-patient ratios and more advanced monitoring than a general wards does, as well as limited organ support. In the UK, the distinctions between ICU, HDU, and general ward have been abandoned in favour of a classification based on the patient’s needs rather than their location.

scholarly journals Rescue stem cell allograft in intensive care unit patients during septic shock with multi-organ failure

2019 ◽  
Vol 54 ◽  
pp. 122-124
Author(s):  
Perrine Leprêtre ◽  
Thomas Clavier ◽  
Anne-Lise Ménard ◽  
Steven Grange ◽  
Christophe Girault ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Septic Shock ◽  
Stem Cell ◽  
Intensive Care ◽  
Organ Failure ◽  
Multi Organ Failure

Admission to the Regular Ward is Safe Following Uncomplicated Craniosynostosis Surgery: A Retrospective Study

FACE ◽  
2021 ◽  
pp. 273250162110279
Author(s):  
Deseray Sileo ◽  
Frank Walch ◽  
Brooke M. French ◽  
Krista Greenan ◽  
Sarah Graber ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Chart Review ◽  
Primary Outcome ◽  
Anesthesia Care ◽  
Post Anesthesia Care Unit ◽  
Icu Admission ◽  
Duration Of Hospitalization ◽  
Secondary Outcomes ◽  
Length Of Hospitalization ◽  
Type Of Surgery

Background: At our craniofacial center patients are routinely admitted to a regular ward, or floor, rather an intensive care unit (ICU) after uncomplicated craniosynostosis surgery. In this study, we review the safety of our postoperative placement policy, examining the rate of transfer from floor to ICU. Methods: The charts of patients who underwent craniosynostosis surgery from 2009 through 2017 at a single children’s hospital were reviewed. Postoperative hospital courses were characterized as preoperatively-planned ICU admission, perioperatively-planned ICU admission, or primary floor admission. The primary outcome was transfer from floor to ICU. Secondary outcomes included duration of hospitalization. Results: Chart review yielded 420 patients. Three hundred sixty-eight (88%) were admitted directly to the floor and 52 (12.0%) directly to an ICU. Of patients admitted to the floor, 2 (0.5%) were transferred to an ICU. Twenty-four patients with syndromic and 20 patients with multisutural craniosynostosis were admitted to the floor. Only 1 patient from each group (the same patient; 4.2% and 5.0%, respectively), was transferred to an ICU. Thirty-two ICU admissions were preoperatively planned and 20 were perioperatively planned. Reasons for preoperatively planned ICU admission included significant comorbidities and type of surgery. Reasons for perioperatively planned ICU admissions included significant intraoperative adverse events, excessive blood loss, and failure of clearance from the post-anesthesia care unit (PACU). Patients admitted to the ICU had a statistically significant longer mean length of hospitalization (4.8 days vs 2.7 days) than did patients admitted to the floor. Conclusions: Most postoperative craniosynostosis surgery patients—including patients with syndromic and/or multisutural synostosis—are managed safely on the floor at our center. Some patients still need postoperative ICU admission, but are easily identified preoperatively, intraoperatively, or in the PACU. Our findings should be applicable to other large craniofacial centers.

Effectiveness of Quetiapine as a Sedative Adjunct in Mechanically Ventilated Adults Without Delirium

2020 ◽  
Vol 55 (2) ◽  
pp. 149-156
Author(s):  
Kelsey L. Ohman ◽  
Jennifer M. Schultheis ◽  
Shawn J. Kram ◽  
Christopher E. Cox ◽  
Daniel L. Gilstrap ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Treatment Period ◽  
Primary Outcome ◽  
Study Cohort ◽  
Mechanically Ventilated ◽  
Percent Time ◽  
Significant Difference ◽  
Sedation Scores ◽  
Secondary Outcomes

Background: Quetiapine is an atypical antipsychotic that is commonly used in the Intensive Care Unit (ICU). The utility of quetiapine as a sedative adjunct has not yet been evaluated, but has been described previously in studies evaluating quetiapine for delirium or delirium prophylaxis. Objective: To determine if adjunctive use of quetiapine reduces sedative dosage requirements among mechanically ventilated adults without delirium. Methods: This retrospective intrapatient comparator study included all mechanically ventilated adults admitted to a medical ICU who received quetiapine between July 1, 2013, and July 1, 2018. The primary outcome was the change in sedative dosage requirements over 24 hours following quetiapine initiation. Secondary outcomes included change in sedative dosage requirements 48 hours postquetiapine initiation, opioid dosage requirements 24 hours postquetiapine initiation, percent time at goal for both pain and sedation scores, depth of sedation, and QTc. Results: A total of 57 patients were included in the study cohort. There was no significant difference in 24-hour cumulative doses of propofol ( P = 0.10), dexmedetomidine ( P = 0.14), or benzodiazepines ( P = 0.14). During the 48-hour treatment period, there was a significant increase in dexmedetomidine requirements ( P = 0.03). There were no differences in 24-hour opioid dosage requirements, percent time at goal pain or sedation scores, depth of sedation, or QTc following quetiapine initiation. Conclusion and Relevance: Adjunctive use of quetiapine was not associated with a significant reduction in sedative dosage requirements 24 or 48 hours following initiation among mechanically ventilated adults without delirium.

Early empirical antimicrobial therapy does not prevent sepsis development in critically ill surgical patients with suspected nosocomial infection: a retrospective analysis

2020 ◽  
Author(s):  
Estêvão Bassi ◽  
Bruno Martins Tomazini ◽  
Bárbara Vieira Carneiro ◽  
Amanda Rodrigues de Oliveira Siqueira ◽  
Sara Rodrigues de Oliveira Siqueira ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Septic Shock ◽  
Nosocomial Infection ◽  
Antibiotic Therapy ◽  
Primary Outcome ◽  
Surgical Patients ◽  
Empiric Antibiotic Therapy ◽  
Conservative Group ◽  
Empiric Antibiotic ◽  
Obvious Source

Abstract Background: Early administration of antibiotics to septic shock patients decreases in-hospital mortality, but there is a lack of studies evaluating the role of early empirical antibiotics in surgical patients with suspected nosocomial infection without sepsis. Methods: Retrospective cohort of adult patients admitted to a surgical Intensive Care Unit in a tertiary hospital. We defined early empirical antibiotic group by the initiation of antibiotic therapy within 24h after infection’s suspicion, and conservative group by antibiotic therapy initiation 24 hours after infection’s suspicion or not prescribed within 14 days. The primary outcome was a composite of death, septic shock or sepsis within 14 days from the clinical suspicion of infection. Regression models were used to identify associations between factors and the primary outcome. Results: From 2007 patients admitted to intensive care unit, 341 surgical patients (71% trauma patients) with suspected nosocomial infection without sepsis and with no obvious source of infection were included in the cohort. Age, gender, traumatic brain injury, admission type (trauma vs. non-trauma), SAPS 3, SOFA, vasopressor use or rate of mechanical ventilation did not differ between early empirical antibiotic and conservative groups. In the conservative group, 57% of patients received antibiotics within 14 days. The composite primary outcome occurred in 41% of patients in the conservative group and 56% in the early empirical antimicrobial group, (p=0.007). The 14-day incidence of septic shock or mortality was similar in both groups. Multivariate analysis showed early antimicrobial therapy (OR 1.83 [95% CI 1.16-2.88] , p = 0.008), non-trauma admission (OR 2.32 [1.40-3.90], p = 0.001) and mechanical ventilation (OR 2.09 [1.31-3.35], p = 0.002) were associated with the primary outcome. Exploratory analysis including only patients with positive cultures also did not find any benefit of early empiric antibiotic therapy (OR 1.39 [0.78-2.49], p = 0.26) Conclusions: Early empiric antibiotic therapy does not decrease the incidence of sepsis, septic shock or death within 14 days in critically ill stable surgical patients with suspected infection but with no obvious source.

Intensive care medicine

2016 ◽  
Keyword(s):  
Intensive Care ◽  
Critical Illness ◽  
Organ Failure ◽  
Intensive Care Medicine ◽  
Basic Science ◽  
Organ Support ◽  
Basic Training ◽  
Basic Principles ◽  
Brainstem Death ◽  
Withdrawal Of Therapy

Chapter 13 covers the basic science and clinical topics relating to intensive care which trainees are required to learn as part of their basic training and demonstrate in the MRCP. It begins with an overview, before covering basic principles of critical illness, organ support in multi-organ failure, management of conditions specific to ICU, and withdrawal of therapy, brainstem death, and organ donation.

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