Chemical Versus Mechanical and Chemical Venous Thromboembolism Prophylaxis in Neurocritically Ill Patients: A Cohort Study

Abstract Background: Patients admitted with neurocritical illness are presumed to be at high risk for venothromboembolism (VTE). The administration of chemical and/or mechanical VTE prophylaxis is a common practice in critically ill patients. Recent data did not show a significant difference in the incidence of VTE between chemical compared to chemical and mechanical VTE prophylaxis in critically ill patients with limited data in neurocritically ill population. The objective of this study is to investigate the incidence of VTE between chemical alone compared to chemical and mechanical VTE prophylaxis in neurocritically ill patients. This was a retrospective cohort study at a tertiary teaching hospital. Data were obtained from electronic medical records for all patients admitted with neurocritical illness from 1/1/2016 to 1/12/2020. Patients were excluded if they did not receive VTE prophylaxis during admission or were younger than 18 YO. Major outcomes were symptomatic VTE based on clinical and radiological findings, intensive care unit (ICU) length of stay (LOS), and hospital LOS. Minor outcomes included severe or life-threatening bleeding based on GUSTO criteria, and mortality at 28-days. Results: Two hundred and twelve patients were included in this study. Patients did not have any significant differences in their baseline characteristics. The incidence of VTE was not different between chemical only compared to chemical and mechanical VTE prophylaxis groups (19/166 (11.3%) vs 7/46 (15.2%); P=0.49. No difference between groups in their ICU LOS 6 [3 – 16.2] vs 6.5 [3 – 19]; P=0.52, nor their mortality (18/166 (10.7%) vs 3/46 (6.5%); P=0.38, respectively. Less bleeding events were seen in the chemical prophylaxis group compared to the combined VTE prophylaxis group (19/166 (11.3%) vs 12/46 (26.1%); P= 0.013. Conclusion: Our findings observed no difference between the administration of chemical prophylaxis alone compared to combined VTE prophylaxis in neurocritically ill patients. More data are needed to confirm this finding with more robust methodology.

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Venous Thromboembolism Prophylaxis in Critically Ill Patients

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0034-1398386 ◽

2015 ◽

Vol 41 (01) ◽

pp. 068-074 ◽

Cited By ~ 21

Author(s):

Kochawan Boonyawat ◽

Mark Crowther

Keyword(s):

Venous Thromboembolism ◽

Critically Ill ◽

Critically Ill Patients ◽

Preventive Measure ◽

Venous Catheter ◽

Bleeding Risk ◽

Contributing Factors ◽

Thromboembolism Prophylaxis ◽

Vte Prophylaxis ◽

Vein Thrombosis

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is recognized as a common complication in critically ill patients. Risk factors including critical illness, mechanical ventilation, sedative medications, and central venous catheter insertion are major contributing factors to the high risk of VTE. Because of their impaired cardiopulmonary reserve, PE arising from thrombosis in the deep veins of the calf that propagates proximally is poorly tolerated by critically ill patients. Pharmacologic prophylaxis with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) has been shown to decrease the incidence of VTE in medical, surgical, and critically ill patients. As a result, over the past decades, VTE prophylaxis had become a standard of preventive measure in the intensive care unit (ICU). In clinical practice, the rate of VTE prophylaxis varies and may be inadequate in some centers. A perception of a high bleeding risk in critically ill patients is a major concern for most physicians that may lead to inadequate prophylaxis.

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Obesity May Not Be Associated with 28-Day Mortality, Duration of Invasive Mechanical Ventilation and Length of Intensive Care Unit and Hospital Stay in Critically Ill Patients with Severe Acute Respiratory Syndrome Coronavirus-2: A Retrospective Cohort Study

Medicina ◽

10.3390/medicina57070674 ◽

2021 ◽

Vol 57 (7) ◽

pp. 674

Author(s):

Sjaak Pouwels ◽

Dharmanand Ramnarain ◽

Emily Aupers ◽

Laura Rutjes-Weurding ◽

Jos van Oers

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Cohort Study ◽

Intensive Care ◽

Length Of Stay ◽

Hospital Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Invasive Mechanical Ventilation ◽

Significant Difference

Background and Objectives: The aim of this study was to investigate the association between obesity and 28-day mortality, duration of invasive mechanical ventilation and length of stay at the Intensive Care Unit (ICU) and hospital in patients admitted to the ICU for SARS-CoV-2 pneumonia. Materials and Methods: This was a retrospective observational cohort study in patients admitted to the ICU for SARS-CoV-2 pneumonia, in a single Dutch center. The association between obesity (body mass index > 30 kg/m2) and 28-day mortality, duration of invasive mechanical ventilation and length of ICU and hospital stay was investigated. Results: In 121 critically ill patients, pneumonia due to SARS-CoV-2 was confirmed by RT-PCR. Forty-eight patients had obesity (33.5%). The 28-day all-cause mortality was 28.1%. Patients with obesity had no significant difference in 28-day survival in Kaplan–Meier curves (log rank p 0.545) compared with patients without obesity. Obesity made no significant contribution in a multivariate Cox regression model for prediction of 28-day mortality (p = 0.124), but age and the Sequential Organ Failure Assessment (SOFA) score were significant independent factors (p < 0.001 and 0.002, respectively). No statistically significant correlation was observed between obesity and duration of invasive mechanical ventilation and length of ICU and hospital stay. Conclusion: One-third of the patients admitted to the ICU for SARS-CoV-2 pneumonia had obesity. The present study showed no relationship between obesity and 28-day mortality, duration of invasive mechanical ventilation, ICU and hospital length of stay. Further studies are needed to substantiate these findings.

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The Impact of Early Achievement of Therapeutic Levels of Vancomycin in Critically ill Patients with Confirmed Gram-positive Infection: A Retrospective Cohort Study

10.21203/rs.3.rs-384175/v2 ◽

2021 ◽

Author(s):

Khalid Al Sulaiman ◽

Abdulrahman Alshaya ◽

Amjad Alsaeed ◽

Nadiyah Alshehri ◽

Ramesh Vishwakarma ◽

...

Keyword(s):

Cohort Study ◽

Critically Ill ◽

Retrospective Cohort Study ◽

Critically Ill Patients ◽

Retrospective Cohort ◽

Kidney Injury ◽

Gram Positive ◽

Tertiary Teaching ◽

The Impact ◽

Trough Levels

Abstract Background: Vancomycin is a commonly used antibiotic in critically ill patients for various indications. Critical illness imposes pharmacokinetic-pharmacodynamics challenges which makes optimizing vancomycin in this population cumbersome. Data are scarce on the clinical impact of time to therapeutic trough levels of vancomycin in critically ill patients. The aim of this study to evaluate the timing to achieve therapeutic trough level vancomycin on 30-day mortality in critically ill patients.Method: A retrospective cohort study for all adult critically ill patients aged 18 years or older with confirmed Gram-positive infection and received vancomycin between January 1st, 2017 and December 31st, 2018 at a tertiary teaching hospital. We compared early (<48 hours) versus late (≥ 48 hours) attainment of vancomycin therapeutic trough levels. Primary outcome was the 30-day mortality in critically ill patients. Secondary outcomes were development of resistant organisms, eradicating microorganisms within 4-5 days of vancomycin initiation, vancomycin-induced acute kidney injury (AKI), and ICU length of stay (LOS). Results: Two hundred and nine patients were included. No significant differences between comparative groups in baseline characteristics. Achieving therapeutic levels were associated with better survival at 30 days (OR: 0.48; 95% CI [0.26-0.87]; p<0.01). Additionally, patients who achieved therapeutic levels of vancomycin early were less likely to develop resistant organisms (OR=0.08; 95% CI [0.01-0.59]; p=0.01). The AKI and ICU LOS were not significant between the two groups.Conclusion: Early attainment of vancomycin therapeutic levels was associated with possible survival benefit.

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Tocilizumab Association with Emerging Multi-drug Resistance Organisms and Mortality in critically ill patients with Coronavirus disease 2019 (COVID-19): A Multicenter, Retrospective Cohort Study

10.21203/rs.3.rs-469073/v1 ◽

2021 ◽

Author(s):

Ohoud Aljuhani ◽

Khalid Al Sulaiman ◽

Adel Alshabasy ◽

Khalid Eljaaly ◽

Abdulrahman I. Al Shaya ◽

...

Keyword(s):

Cohort Study ◽

Respiratory Failure ◽

Critically Ill ◽

Retrospective Cohort Study ◽

Critically Ill Patients ◽

Retrospective Cohort ◽

Resistant Bacteria ◽

Microbial Isolation ◽

Increased Risk ◽

Significant Difference

Abstract Background:Tocilizumab is an IgG1 class recombinant humanized monoclonal antibody that directly inhibits IL-6 receptor. Several randomized clinical trials (RCTs) have evaluated tocilizumab’s safety and efficacy in patients with COVID-19. These studies demonstrated conflicting results regarding tocilizumab’s efficacy and safety. Our study aim is to determine the association between treatment with tocilizumab and emergence of multidrug-resistant bacteria and its effect on mortality in critically ill patients with Coronavirus disease 2019 (COVID-19).Methods:A multicenter, retrospective, cohort study conducted at two governmental tertiary hospitals in Saudi Arabia. All critically ill patients who were admitted to intensive care units (ICUs) with a positive COVID-19 PCR test between March 1st, 2020 and January 31st, 2021 were included. Patients who received tocilizumab were compared to patients who did not receive it. Results:A total of 738 patients met our inclusion criteria and were included in the analysis. Of these 262 (35.5%) received tocilizumab and 476 (64.5%) were included in the control group. Patients who received tocilizumab did not have higher odds for the microbial isolation (OR 1.34; 95% CI, 0.91-1.94 p = 0.13), development of resistant organisms (OR 1.00; 95% CI, 0.51-1.98 p = 0.99), or detection of Carbapenem-Resistant Enterobacteria (CRE) (OR 0.67; 95% CI, 0.29-1.54 p = 0.34). In a multivariable logistic regression adjusting for possible cofounders, there was no difference in 30-day ICU mortality (OR 0.96; 95% CI, 0.65-1.43 p = 0.85) or in-hospital mortality (OR 1.18; 95% CI, 0.79-1.76 p = 0.42). However, there was a significant difference in the incidence of respiratory failure requiring MV between the two groups (OR 2.27; 95% CI, 1.05-4.89 p = 0.03).Conclusions: Tocilizumab use in critically ill COVID-19 patients was not associated with microbial isolation, emergence of resistant organisms, detection of CRE organisms, or mortality benefits. However, tocilizumab use was associated with an increased risk of respiratory failure requiring mechanical ventilation.

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Convalescent plasma is of limited clinical benefit in critically ill patients with coronavirus disease-2019: a cohort study

Journal of Translational Medicine ◽

10.1186/s12967-021-03028-5 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Li Huang ◽

Che Zhang ◽

Xihui Zhou ◽

Zhou Zhao ◽

Weiping Wang ◽

...

Keyword(s):

Cohort Study ◽

Critically Ill ◽

Critically Ill Patients ◽

Clinical Benefit ◽

Clinical Characteristics ◽

Clinical Evidence ◽

Control Group ◽

Cumulative Mortality ◽

Kaplan Meier ◽

Significant Difference

Abstract Background Recently, convalescent plasma (CP) transfusion was employed for severe or critically ill patients with coronavirus disease-2019. However, the benefits of CP for patients with different conditions are still in debate. To contribute clinical evidence of CP on critically ill patients, we analyze the characteristics and outcomes of patients with or without CP transfusion. Methods In this cohort study, 14 patients received CP transfusion based on the standard treatments, whereas the other 10 patients received standard treatments as control. Clinical characteristics and outcomes were analyzed. The cumulative survival rate was calculated by Kaplan–Meier survival analysis. Results Data analysis was performed on 24 patients (male/female: 15/9) with a median age of 64.0 (44.5–74.5) years. Transient fever was reported in one patient. The cumulative mortality was 21% (3/14) in patients receiving CP transfusion during a 28-day observation, whereas one dead case (1/10) was reported in the control group. No significant difference was detected between groups in 28-day mortality (P = 0.615) and radiological alleviation of lung lesions (P = 0.085). Conclusion In our current study, CP transfusion was clinically safe based on the safety profile; however, the clinical benefit was not significant in critically ill patients with more comorbidities at the late stage of disease during a 28-day observation. Graphic abstract

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Appropriateness of using vitamin K for the correction of INR elevation secondary to hepatic disease in critically ill patients: An Observational Study

10.21203/rs.3.rs-623623/v3 ◽

2021 ◽

Author(s):

Khalid Al Sulaiman ◽

Mashael Al Mutairi ◽

Omar Al Harbi ◽

Alanoud Al Duraihim ◽

Sara Aldosary ◽

...

Keyword(s):

Liver Disease ◽

Critically Ill ◽

Vitamin K ◽

Critically Ill Patients ◽

Thrombotic Event ◽

Bleeding Events ◽

Hepatic Diseases ◽

Increased Risk ◽

Severity Scores ◽

Tertiary Teaching

Abstract Background: Hepatic diseases have been associated with an increased risk of coagulopathy and increased odds of secondary thrombosis and bleeding. Using vitamin K for correction of coagulopathy in critically ill patients is controversial with limited evidence. This study aims to evaluate the efficacy and safety of vitamin K in the correction of international normalized ratio (INR) elevation secondary to liver disease in critically ill patients.Method: A retrospective study of adult ICU patients with coagulopathy secondary to liver disease admitted to a tertiary teaching hospital in Saudi Arabia. The primary outcome was to evaluate the association between vitamin K administration and the incidence of new bleeding events in critically ill patients with INR elevation secondary to liver disease. Secondary outcomes were to evaluate the incidence of a new thrombotic event, and the degree of INR correction with vitamin K. Patients were divided into two groups based on vitamin K administration to correct INR elevation. The propensity score was generated based on disease severity scores and the use of pharmacological DVT prophylaxis. Results: A total of 98 patients were included in the study. Forty-seven patients (48%) received vitamin K during the study period. The incidence of the new bleeding event was not statistically different between groups (OR 2.4, 95% CI 0.28-21.67, P=0.42). Delta of INR reduction was observed with a median of 0.63 when the first dose is given (p-value: <.0001). However, other subsequent doses of vitamin K were not statistically significant.Conclusion: Using vitamin K for INR correction in critically ill patients with coagulopathy secondary to liver disease was not associated with a lower incidence of new bleeding events. Vitamin K was efficient in reducing INR level at the first dose, and other subsequent doses were not.

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Appropriateness of using vitamin K for the correction of INR elevation secondary to hepatic disease in critically ill patients: An Observational Study

10.21203/rs.3.rs-623623/v2 ◽

2021 ◽

Author(s):

Khalid Al Sulaiman ◽

Mashael Al Mutairi ◽

Omar Al Harbi ◽

Alanoud Al Duraihim ◽

Sara Aldosary ◽

...

Keyword(s):

Liver Disease ◽

Critically Ill ◽

Vitamin K ◽

Critically Ill Patients ◽

Lower Incidence ◽

Bleeding Events ◽

Hepatic Diseases ◽

Increased Risk ◽

Severity Scores ◽

Tertiary Teaching

Abstract Background: Hepatic diseases have been associated with an increased risk of coagulopathy and increased odds of secondary thrombosis and bleeding. Using vitamin K for correction of coagulopathy in critically ill patients is controversial with limited evidence.Objective: To evaluate the efficacy as well as safety of vitamin K in correction of international normalized ratio (INR) elevation secondary to liver disease in critically ill patients.Setting: Tertiary teaching hospital in Saudi Arabia.Method: A retrospective case-control study of adult ICU patients with coagulopathy secondary to liver disease. A total of 98 patients were included in the study. Patients were divided into two groups based on vitamin K administration to correct INR elevation. differences. The propensity score was generated based on disease severity scores to adjust group.Main outcomes: The primary outcome was to evaluate the association between vitamin K administration and the incidence of new bleeding events in critically ill patients with INR elevation secondary to liver disease. Secondary outcomes were to evaluate the incidence of a new thrombotic event and the degree of INR correction with vitamin K. Results: Forty-seven patients (48%) received vitamin K during the study period. The incidence of the new bleeding event was not statistically different between groups (OR 2.4, 95% CI 0.28-21.67, P=0.42). Delta of INR reduction was observed with a median of 0.63 when the first dose is given (p-value: <.0001). However, other subsequent doses of vitamin K were not statistically significant.Conclusion: Using vitamin K for INR correction in critically ill patients with coagulopathy secondary to liver disease was not associated with a lower incidence of new bleeding events. Vitamin K was efficient in reducing INR level at the first dose, other subsequent doses were not.Impacts on practice: 1. Routine use of vitamin K to correct PT/INR in critically ill patients with liver disease may need be re-evaluated.2. If the initial dose of vitamin K does not reverse INR elevation, subsequent doses may not have any effect.3. Using vitamin K to correct INR was not associated with a lower incidence of new bleeding events nor RBCs/Platelets transfusion than patients who did not receive it.

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Appropriateness of using vitamin K for the correction of INR elevation secondary to hepatic disease in critically ill patients: An Observational Study

10.21203/rs.3.rs-623623/v1 ◽

2021 ◽

Author(s):

Khalid Al Sulaiman ◽

Mashael Al Mutairi ◽

Omar Al Harbi ◽

Alanoud Al Duraihim ◽

Sara Aldosary ◽

...

Keyword(s):

Liver Disease ◽

Critically Ill ◽

Vitamin K ◽

Critically Ill Patients ◽

Lower Incidence ◽

Bleeding Events ◽

Hepatic Diseases ◽

Increased Risk ◽

Severity Scores ◽

Tertiary Teaching

Abstract Background Hepatic diseases have been associated with an increased risk of coagulopathy and increased odds of secondary thrombosis and bleeding. Using vitamin K for correction of coagulopathy in critically ill patients is controversial with limited evidence. Objective To evaluate the efficacy as well as safety of vitamin K in correction of international normalized ratio (INR) elevation secondary to liver disease in critically ill patients. Setting Tertiary teaching hospital in Saudi Arabia. Method A retrospective case-control study of adult ICU patients with coagulopathy secondary to liver disease. A total of 98 patients were included in the study. Patients were divided into two groups based on vitamin K administration to correct INR elevation. differences. The propensity score was generated based on disease severity scores to adjust group. Main outcomes The primary outcome was to evaluate the association between vitamin K administration and the incidence of new bleeding events in critically ill patients with INR elevation secondary to liver disease. Secondary outcomes were to evaluate the incidence of a new thrombotic event and the degree of INR correction with vitamin K. Results Forty-seven patients (48%) received vitamin K during the study period. The incidence of the new bleeding event was not statistically different between groups (OR 2.4, 95% CI 0.28-21.67, P=0.42). Delta of INR reduction was observed with a median of 0.63 when the first dose is given (p-value: <.0001). However, other subsequent doses of vitamin K were not statistically significant. Conclusion Using vitamin K for INR correction in critically ill patients with coagulopathy secondary to liver disease was not associated with a lower incidence of new bleeding events. Vitamin K was efficient in reducing INR level at the first dose, other subsequent doses were not.Impacts on practice: Routine use of vitamin K to correct PT/INR in critically ill patients with liver disease may need be re-evaluated.If the initial dose of vitamin K does not reverse INR elevation, subsequent doses may not have any effect.Using vitamin K to correct INR was not associated with a lower incidence of new bleeding events nor RBCs/Platelets transfusion than patients who did not receive it.

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Can the cytokine adsorber CytoSorb® help to mitigate cytokine storm and reduce mortality in critically ill patients? A propensity score matching analysis

Annals of Intensive Care ◽

10.1186/s13613-021-00905-6 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Christina Scharf ◽

Ines Schroeder ◽

Michael Paal ◽

Martin Winkels ◽

Michael Irlbeck ◽

...

Keyword(s):

Propensity Score ◽

Critically Ill ◽

Critically Ill Patients ◽

Wilcoxon Test ◽

Relative Reduction ◽

Cytokine Storm ◽

Saps Ii ◽

Significant Difference ◽

Group 2 ◽

Group 1

Abstract Background A cytokine storm is life threatening for critically ill patients and is mainly caused by sepsis or severe trauma. In combination with supportive therapy, the cytokine adsorber Cytosorb® (CS) is increasingly used for the treatment of cytokine storm. However, it is questionable whether its use is actually beneficial in these patients. Methods Patients with an interleukin-6 (IL-6) > 10,000 pg/ml were retrospectively included between October 2014 and May 2020 and were divided into two groups (group 1: CS therapy; group 2: no CS therapy). Inclusion criteria were a regularly measured IL-6 and, for patients allocated to group 1, CS therapy for at least 90 min. A propensity score (PS) matching analysis with significant baseline differences as predictors (Simplified Acute Physiology Score (SAPS) II, extracorporeal membrane oxygenation, renal replacement therapy, IL-6, lactate and norepinephrine demand) was performed to compare both groups (adjustment tolerance: < 0.05; standardization tolerance: < 10%). U-test and Fisher’s-test were used for independent variables and the Wilcoxon test was used for dependent variables. Results In total, 143 patients were included in the initial evaluation (group 1: 38; group 2: 105). Nineteen comparable pairings could be formed (mean initial IL-6: 58,385 vs. 59,812 pg/ml; mean SAPS II: 77 vs. 75). There was a significant reduction in IL-6 in patients with (p < 0.001) and without CS treatment (p = 0.005). However, there was no significant difference (p = 0.708) in the median relative reduction in both groups (89% vs. 80%). Furthermore, there was no significant difference in the relative change in C-reactive protein, lactate, or norepinephrine demand in either group and the in-hospital mortality was similar between groups (73.7%). Conclusion Our study showed no difference in IL-6 reduction, hemodynamic stabilization, or mortality in patients with Cytosorb® treatment compared to a matched patient population.

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

Annals of Intensive Care ◽

10.1186/s13613-020-00652-0 ◽

2020 ◽

Vol 10 (1) ◽

Cited By ~ 3

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.

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