Dexmedetomidine versus midazolam and propofol for sedation in critically ill patients: Mining the Medical Information Mart for Intensive Care data

We aimed to clarify associations between nutritional status and mortality in patients with acute renal failure. De-identified data were obtained from the Medical Information Mart for Intensive Care III database comprising more than 40,000 critical care patients treated at Beth Israel Deaconess Medical Centerbetween 2001 and 2012. Weight loss and body mass index criteria were used to define malnutrition. Data of 193 critically ill patients with acute renal failure were analyzed, including demographics, nutrition intervention, laboratory results, and disease severity. Main outcomes were in-hospital and 1-year mortality. The 1-year mortality was significantly higher in those with malnutrition than in those without malnutrition (50.0% vs 29.3%, p=0.010), but differences in in-hospital survival were not significant (p=0.255). Significant differences in mortality were found between those with malnutrition and without starting at the 52nd day after intensive care unit (ICU) discharge (p=0.036). No significant differences were found between men and women with malnutrition in in-hospital mortality (p=0.949) and 1-year mortality (p=0.051). Male patients requiring intervention with blood products/colloid supplements had greater risk of 1-year mortality, but without statistical significance. Nutritional status is a predictive factor for mortality among critically ill patients with acute renal failure, particularly 1-year mortality after ICU discharge.

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Acute Kidney Injury Associated with Combination Antimicrobial Therapy in the Medical Information Mart for Intensive Care (MIMIC) III Database

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.821 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S344-S344

Author(s):

W Cliff Rutter ◽

David S Burgess

Keyword(s):

Acute Kidney Injury ◽

Logistic Regression ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Hepatorenal Syndrome ◽

Medical Information ◽

Kidney Injury ◽

Rifle Criteria ◽

Multivariable Logistic Regression

Abstract Background Increased acute kidney injury (AKI) incidence is linked with coadministration of vancomycin (VAN) and piperacillin-tazobactam (TZP) in the general hospital population when compared with VAN and cefepime (FEP); however, this phenomenon was not found in critically ill patients. Methods Patients receiving VAN in combination with FEP or TZP for at least 48 hours during an intensive care unit stay were included in this retrospective review. AKI was defined with the Risk, Injury, Failure, Loss, and End-stage (RIFLE) criteria. Exposure to common nephrotoxins was captured within 24 hours of combination therapy initiation through the entire treatment window. Basic descriptive statistics were performed, along with bivariable and multivariable logistic regression models of AKI odds. Results In total, 2230 patients were included, with 773 receiving FEP+VAN and 1457 receiving TZP+VAN. The groups were well balanced at baseline in most covariates, with the exception of hepatorenal syndrome diagnosis (TZP+VAN 1.4% vs. FEP+VAN 0.3%, P = 0.02) and vasopressor exposure (TZP+VAN 26.2% vs 21.5%, P = 0.01) being more common in the TZP+VAN group. Patients in the FEP+VAN group had a higher underlying severity of disease (Charlson comorbidity index [CCI] 2.7 vs. 2.3, P =0.0002). AKI incidence was higher in the TZP+VAN cohort (35.1% vs. 26.5%, P = 0.00004), with each stratification of the RIFLE criteria being higher. The time until onset of AKI was similar between groups (TZP+VAN median 1 [0–3] days vs. FEP+VAN 1 [0–4] days, P =0.2). After multivariable logistic regression, TZP+VAN therapy was associated with an adjust odds ratio (aOR) of AKI of 1.54 (95% confidence interval [CI] 1.25–1.89) compared with FEP+VAN. Other variables associated with increased odds of AKI included: age >= 65, duration of antibiotic therapy, higher baseline renal function, sepsis, endocarditis, hepatorenal syndrome, thiazide diuretic exposure, and increased CCI. Conclusion Treatment with TZP+VAN is associated with significant increases in AKI incidence among critically ill patients, independent of other risks for AKI. Disclosures All authors: No reported disclosures.

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Development and validation of an automated algorithm to detect atrial fibrillation within stored intensive care unit continuous electrocardiographic data (Preprint)

10.2196/preprints.18840 ◽

2020 ◽

Author(s):

Allan J Walkey ◽

Syed K Bashar ◽

Billal Hossain ◽

Eric Ding ◽

Daniella Albuquerque ◽

...

Keyword(s):

Atrial Fibrillation ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Medical Information ◽

Heart Rhythm ◽

Adverse Outcomes ◽

Healthcare Data ◽

Automated Algorithm ◽

Large Databases

BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia during critical illness, representing a sepsis-defining cardiac dysfunction associated with adverse outcomes. OBJECTIVE To develop and validate an automated algorithm to accurately identify AF within electronic healthcare data among critically ill patients with sepsis. METHODS Retrospective cohort study of patients hospitalized with sepsis identified from Medical Information Mart for Intensive Care (MIMIC III) electronic health data with linked electrocardiographic (ECG) telemetry waveforms. Within three separate cohorts of 50 patients, we iteratively developed and validated an automated algorithm that identifies ECG signals, removes noise, and identifies irregularly irregular rhythm and premature beats in order to identify AF. We compared the automated algorithm to current methods of AF identification in large databases, including ICD-9 codes and hourly nurse annotation of heart rhythm. Methods of AF identification were tested against gold standard manual ECG review. RESULTS AF detection algorithms that did not differentiate AF from premature atrial and ventricular beats performed modestly, with 76% (95% CI, 61-87%) accuracy. Performance improved (p=0.02) with the addition of premature beat detection (validation set accuracy: 94% [95% CI, 83-99%]). Median time between automated and manual detection of AF onset was 30 minutes (25th-75%ile 0-208 minutes). The accuracy of ICD-9 codes (68%, p=0.0002 vs. automated algorithm) and nurse charting (80%, p=0.02 vs. algorithm) was lower than the automated algorithm. CONCLUSIONS An automated algorithm using telemetry ECG data can feasibly and accurately detect AF among critically ill patients with sepsis, and represents an improvement in AF detection within large databases. CLINICALTRIAL na

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Lung Microbiota Analysis in Critically Ill Patients Admitted to the Intensive Care Unit.

Case Medical Research ◽

10.31525/ct1-nct04271345 ◽

2020 ◽

Author(s):

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Microbiota Analysis

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Intensive Care Unit Organization and Interdisciplinary Care for Critically Ill Patients with Cancer

Critical Care Clinics ◽

10.1016/j.ccc.2020.09.003 ◽

2021 ◽

Vol 37 (1) ◽

pp. 19-28

Author(s):

Alexander Shimabukuro-Vornhagen

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Interdisciplinary Care ◽

Patients With Cancer ◽

Unit Organization

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Report of the first AKI Round Table meeting: an initiative of the ESICM AKI Section

Intensive Care Medicine Experimental ◽

10.1186/s40635-019-0280-z ◽

2019 ◽

Vol 7 (1) ◽

Cited By ~ 1

Author(s):

M. Ostermann ◽

A. Schneider ◽

T. Rimmele ◽

I. Bobek ◽

M. van Dam ◽

...

Keyword(s):

Blood Pressure ◽

Critical Care ◽

Intensive Care ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Critically Ill ◽

Critically Ill Patients ◽

Future Research ◽

Knowledge Gaps ◽

Blood Pressure Targets

Abstract Purpose Critical Care Nephrology is an emerging sub-specialty of Critical Care. Despite increasing awareness about the serious impact of acute kidney injury (AKI) and renal replacement therapy (RRT), important knowledge gaps persist. This report represents a summary of a 1-day meeting of the AKI section of the European Society of Intensive Care Medicine (ESICM) identifying priorities for future AKI research. Methods International Members of the AKI section of the ESICM were selected and allocated to one of three subgroups: “AKI diagnosis and evaluation”, “Medical management of AKI” and “Renal Replacement Therapy for AKI.” Using a modified Delphi methodology, each group identified knowledge gaps and developed potential proposals for future collaborative research. Results The following key research projects were developed: Systematic reviews: (a) epidemiology of AKI with stratification by patient cohorts and diagnostic criteria; (b) role of higher blood pressure targets in patients with hypertension admitted to the Intensive Care Unit, and (c) specific clearance characteristics of different modalities of continuous renal replacement therapy (CRRT). Observational studies: (a) epidemiology of critically ill patients according to AKI duration, and (b) current clinical practice of CRRT. Intervention studies:( a) Comparison of different blood pressure targets in critically ill patients with hypertension, and (b) comparison of clearance of solutes with various molecular weights between different CRRT modalities. Conclusion Consensus was reached on a future research agenda for the AKI section of the ESICM.

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Cystatin C predicts long term mortality better than creatinine in a nationwide study of intensive care patients

Scientific Reports ◽

10.1038/s41598-021-85370-8 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Johanna Helmersson-Karlqvist ◽

Miklos Lipcsey ◽

Johan Ärnlöv ◽

Max Bell ◽

Bo Ravn ◽

...

Keyword(s):

Intensive Care ◽

Critically Ill ◽

Risk Prediction ◽

Cystatin C ◽

Mortality Risk ◽

Critically Ill Patients ◽

Cox Regression ◽

Sample Tube ◽

Long Term Mortality

AbstractDecreased glomerular filtration rate (GFR) is linked to poor survival. The predictive value of creatinine estimated GFR (eGFR) and cystatin C eGFR in critically ill patients may differ substantially, but has been less studied. This study compares long-term mortality risk prediction by eGFR using a creatinine equation (CKD-EPI), a cystatin C equation (CAPA) and a combined creatinine/cystatin C equation (CKD-EPI), in 22,488 patients treated in intensive care at three University Hospitals in Sweden, between 2004 and 2015. Patients were analysed for both creatinine and cystatin C on the same blood sample tube at admission, using accredited laboratory methods. During follow-up (median 5.1 years) 8401 (37%) patients died. Reduced eGFR was significantly associated with death by all eGFR-equations in Cox regression models. However, patients reclassified to a lower GFR-category by using the cystatin C-based equation, as compared to the creatinine-based equation, had significantly higher mortality risk compared to the referent patients not reclassified. The cystatin C equation increased C-statistics for death prediction (p < 0.001 vs. creatinine, p = 0.013 vs. combined equation). In conclusion, this data favours the sole cystatin C equation rather than the creatinine or combined equations when estimating GFR for risk prediction purposes in critically ill patients.

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Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era

Journal of Intensive Care Medicine ◽

10.1177/0885066620988281 ◽

2021 ◽

pp. 088506662098828

Author(s):

Madhumita Premkumar ◽

Kamal Kajal ◽

Anand V. Kulkarni ◽

Ankur Gupta ◽

Smita Divyaveer

Keyword(s):

Intensive Care ◽

Liver Failure ◽

Critically Ill ◽

Critically Ill Patients ◽

Point Of Care ◽

Kidney Injury ◽

Regional Wall Motion ◽

Chronic Liver ◽

Chronic Liver Failure ◽

Evidenced Based

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to “collateral damage” in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

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Impact of Renal Replacement Therapy on Mortality in Critically Ill Patients—The Nephrologist’s View within an Interdisciplinary Intensive Care Team

Journal of Clinical Medicine ◽

10.3390/jcm10153379 ◽

2021 ◽

Vol 10 (15) ◽

pp. 3379

Author(s):

Matthias Klingele ◽

Lea Baerens

Keyword(s):

Intensive Care ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Critically Ill ◽

Critically Ill Patients ◽

Positive Impact ◽

Kidney Injury ◽

Care Team ◽

Critically Ill Patient ◽

Late Start

Acute kidney injury (AKI) is a common complication in critically ill patients with an incidence of up to 50% in intensive care patients. The mortality of patients with AKI requiring dialysis in the intensive care unit is up to 50%, especially in the context of sepsis. Different approaches have been undertaken to reduce this high mortality by changing modalities and techniques of renal replacement therapy: an early versus a late start of dialysis, high versus low dialysate flows, intermittent versus continuous dialysis, anticoagulation with citrate or heparin, the use of adsorber or special filters in case of sepsis. Although in smaller studies some of these approaches seemed to have a positive impact on the reduction of mortality, in larger studies these effects could not been reproduced. This raises the question of whether there exists any impact of renal replacement therapy on mortality in critically ill patients—beyond an undeniable impact on uremia, hyperkalemia and/or hypervolemia. Indeed, this is one of the essential challenges of a nephrologist within an interdisciplinary intensive care team: according to the individual situation of a critically ill patient the main indication of dialysis has to be identified and all parameters of dialysis have to be individually chosen with respect to the patient’s situation and targeting the main dialysis indication. Such an interdisciplinary and individual approach would probably be able to reduce mortality in critically ill patients with dialysis requiring AKI.

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Treatment of a Critically Ill COVID-19 Patient with the Seraph 100 Microbind Affinity Filter

TH Open ◽

10.1055/s-0041-1727121 ◽

2021 ◽

Vol 05 (02) ◽

pp. e134-e138

Author(s):

Anke Pape ◽

Jan T. Kielstein ◽

Tillman Krüger ◽

Thomas Fühner ◽

Reinhard Brunkhorst

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Randomized Trials ◽

Clinical Course ◽

Pharmacological Therapy ◽

The European Union ◽

Positive Effects ◽

Special Patient

AbstractThe coronavirus disease 2019 (COVID-19) pandemic has a serious impact on health and economics worldwide. Even though the majority of patients present with moderate and mild symptoms, yet a considerable portion of patients need to be treated in the intensive care unit. Aside from dexamethasone, there is no established pharmacological therapy. Moreover, some of the currently tested drugs are contraindicated for special patient populations like remdesivir for patients with severely impaired renal function. On this background, several extracorporeal treatments are currently explored concerning their potential to improve the clinical course and outcome of critically ill patients with COVID-19. Here, we report the use of the Seraph 100 Microbind Affinity filter, which is licensed in the European Union for the removal of pathogens. Authorization for emergency use in patients with COVID-19 admitted to the intensive care unit with confirmed or imminent respiratory failure was granted by the U.S. Food and Drug Administration on April 17, 2020.A 53-year-old Caucasian male with a severe COVID-19 infection was treated with a Seraph Microbind Affinity filter hemoperfusion after clinical deterioration and commencement of mechanical ventilation. The 70-minute treatment at a blood flow of 200 mL/minute was well tolerated, and the patient was hemodynamically stable. The hemoperfusion reduced D-dimers dramatically.This case report suggests that the use of Seraph 100 Microbind Affinity filter hemoperfusion might have positive effects on the clinical course of critically ill patients with COVID-19. However, future prospective collection of data ideally in randomized trials will have to confirm whether the use of Seraph 100 Microbind Affinity filter hemoperfusion is an option of the treatment for COVID-19.

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