scholarly journals Comparative Evaluation of the Prognosis of Septic Shock Patients from before to after the Onset of the COVID-19 Pandemic: A Retrospective Single-Center Clinical Analysis

2022 ◽  
Vol 12 (1) ◽  
pp. 103
Author(s):  
Jae Hwan Kim ◽  
Chiwon Ahn ◽  
Myeong Namgung

In this study, we investigated the mortality of septic shock patients visiting emergency departments (ED) before and after the coronavirus disease (COVID-19) pandemic onset. We retrospectively reviewed medical records and National Emergency Department Information System data of septic shock patients who visited the ED of a tertiary medical center in South Korea from February 2019 to February 2021. Following the COVID-19 pandemic onset, revised institutional ED processes included a stringent isolation protocol for patients visiting the ED. The primary goal of this study was to determine the mortality rate of septic shock patients from before and after the onset of the COVID-19 pandemic. Durations of vasopressor use, mechanical ventilation, intensive care unit stay, and hospitalization were investigated. The mortality rates increased from 24.8% to 35.8%, before and after COVID-19-onset, but the difference was not statistically significant (p = 0.079). No significant differences in other outcomes were found. Multivariable analysis revealed that the Simplified Acute Physiology Score III (SAPS III) was the only risk factor for mortality (OR 1.07; 95% CI 1.04-1.10), whereas COVID-19 pandemic was not included in the final model. The non-significant influence of the COVID-19 pandemic on septic shock mortality rates in the present study belies the actual mortality-influencing potential of the COVID-19 pandemic.

Author(s):  
Wenyan Liu ◽  
Yang Yan ◽  
Dan Han ◽  
Yongxin Li ◽  
Qian Wang ◽  
...  

Abstract Background Systemic inflammation contributes to cardiac surgery–associated acute kidney injury (AKI). Cardiomyocytes and other organs experience hypothermia and hypoxia during cardiopulmonary bypass (CPB), which induces the secretion of cold-inducible RNA-binding protein (CIRP). Extracellular CIRP may induce a proinflammatory response. Materials and Methods The serum CIRP levels in 76 patients before and after cardiac surgery were determined to analyze the correlation between CIRP levels and CPB time. The risk factors for AKI after cardiac surgery and the in-hospital outcomes were also analyzed. Results The difference in the levels of CIRP (ΔCIRP) after and before surgery in patients who experienced cardioplegic arrest (CA) was 26-fold higher than those who did not, and 2.7-fold of those who experienced CPB without CA. The ΔCIRP levels were positively correlated with CPB time (r = 0.574, p < 0.001) and cross-clamp time (r = 0.54, p < 0.001). Multivariable analysis indicated that ΔCIRP (odds ratio: 1.003; 95% confidence interval: 1.000–1.006; p = 0.027) was an independent risk factor for postoperative AKI. Patients who underwent aortic dissection surgery had higher levels of CIRP and higher incidence of AKI than other patients. The incidence of AKI and duration of mechanical ventilation in patients whose serum CIRP levels more than 405 pg/mL were significantly higher than those less than 405 pg/mL (65.8 vs. 42.1%, p = 0.038; 23.1 ± 18.2 vs. 13.8 ± 9.2 hours, p = 0.007). Conclusion A large amount of CIRP was released during cardiac surgery. The secreted CIRP was associated with the increased risk of AKI after cardiac surgery.


2021 ◽  
pp. 088506662110617
Author(s):  
Tanveer Mir ◽  
Mohammed Uddin ◽  
Waqas T. Qureshi ◽  
Shady Abohashem ◽  
Shehabaldin Alqalyoobi ◽  
...  

Objective To study coronary interventions and mortality among patients with ST-elevated myocardial infarction (STEMI) who were admitted with septic shock. Methods Data from the national emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments in the United States was analyzed for the septic shock related visits from 2016 to 2018. Septic shock was defined by the ICD codes. Results Out of 1 375 507 adult septic shock patients, 521 300 had a primary diagnosis of septic shock (mean age 67.41±15.67 years, 51.1% females) in the national emergency database for the years 2016 to 2018. Of these patients, 2768 (0.53%) had STEMI recorded during the hospitalization. Mortality rates for STEMI patients were higher than patients without STEMI (52.3% vs 23.5%). Mortality rates improved with PCI among STEMI patients (43.8% vs 56.2%). Coronary angiography was performed among 16% of patients of which percutaneous coronary intervention (PCI) rates were 7.7% among patients with STEMI septic shock. PCI numerically improved mortality, however, had no significant difference than patients without PCI on multivariate logistic regression and univariate logistic regression post coarsened exact matching of baseline characteristics among STEMI patients. Among the predictors, STEMI was a significant predictor of mortality in septic shock patients (OR 2.87, 95% CI 2.37-3.49; P<.001). Age, peripheral vascular disease, were predominant predictors of mortality in STEMI with septic shock subgroup ( P <.001). Pneumonia was the predominant underlying infection among STEMI (36.4%) and without STEMI group (29.5%). Conclusion STEMI complicating septic shock worsens mortality. PCI and coronary angiography numerically improved mortality, however, had no significant difference from patients without PCI. More research will be needed to improve mortality in such a critically ill subgroup of patients.


2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e19036-e19036
Author(s):  
Phaedon D. Zavras ◽  
Prateek Pophali ◽  
Aditi Shastri ◽  
Lizamarie Bachier-Rodriguez ◽  
Alejandro R. Sica ◽  
...  

e19036 Background: Recent studies have shown smoking to be an independent risk factor for MDS. We aimed to assess whether smoking is associated with worse outcomes among patients (pts) with MDS at Montefiore Medical Center, Bronx, NY. Methods: Pts with MDS and chronic myelomonocytic leukemia (CMML) diagnosed between June 16, 2000 and November 13, 2020 were analyzed. Those without available tissue diagnosis or smoking history data were excluded. Descriptive statistics compared ever-smokers to non-smokers. Cox PH regression was used to analyze the risk of transformation to acute myeloid leukemia (AML) and mortality in the 2 groups and multivariable analysis (MVA) adjusted for age, sex, de novo disease and R-IPSS. Results: A total of 147 pts were identified, 109 (74.1%) had a diagnosis of de novo MDS, 89 (60.5%) had history of active or former smoking and 58 (39.5%) were non-smokers. Smokers were predominantly males (66.3%) in contrast to non-smokers (37.9%) (p=0.001). Smokers were diagnosed more frequently with high or very high risk MDS, although the difference was not statistically significant (38.1% vs 28.6%, respectively; p=0.28). TP53 mutations were numerically more frequent among smokers (24.4%), compared to non-smokers (12.8%) (p=0.16). Median follow-up time for smokers and non-smokers was 19.4 and 31.4 months, respectively. In MVA, there was a trend for increased risk of AML transformation in smokers vs non-smokers (HR 2.03, 95% CI 0.99 – 4.15; p=0.052). Smokers with MDS were found to have significantly greater mortality compared to non-smokers (HR 2.08, 95% CI, 1.22 – 3.54; p=0.007). Conclusions: Smoking was associated with worse survival among MDS pts in our cohort. Although not significantly different, the prevalence of TP53 mutations was higher among smokers. Larger studies are warranted to confirm our findings.[Table: see text]


2018 ◽  
Vol 62 (6) ◽  
Author(s):  
Alessandro Russo ◽  
Simone Giuliano ◽  
Giancarlo Ceccarelli ◽  
Francesco Alessandri ◽  
Alessandra Giordano ◽  
...  

ABSTRACTA significant cause of mortality in the intensive care unit (ICU) is multidrug-resistant (MDR) Gram-negative bacteria, such as MDRAcinetobacter baumannii(MDR-AB) andKlebsiella pneumoniaecarbapenemase-producingK. pneumoniae(KPC-Kp). The aim of the present study was to compare the clinical features, therapy, and outcome of patients who developed septic shock due to either MDR-AB or KPC-Kp. We retrospectively analyzed patients admitted to the ICU of a teaching hospital from November 2010 to December 2015 who developed septic shock due to MDR-AB or KPC-Kp infection. Data from 220 patients were analyzed: 128 patients (58.2%) were diagnosed with septic shock due to KPC-Kp, and 92 patients (41.8%) were diagnosed with septic shock due to MDR-AB. The 30-day mortality rate was significantly higher for the MDR-AB group than the KPC-Kp group (84.8% versus 44.5%, respectively;P< 0.001). Steroid exposure and pneumonia were associated with MDR-AB infection, whereas hospitalization in the previous 90 days, primary bacteremia, and KPC-Kp colonization were associated with KPC-Kp infection. For patients with KPC-Kp infections, the use of ≥2in vitro-active antibiotics as empirical or definitive therapy was associated with higher 30-day survival, while isolation of colistin-resistant strains was linked to mortality. Patients with MDR-AB infections, age >60 years, and a simplified acute physiology score II (SAPS II) of >45 points were associated with increased mortality rates. We concluded that septic shock due to MDR-AB infection is associated with very high mortality rates compared to those with septic shock due to KPC-Kp. Analysis of the clinical features of these critically ill patients might help physicians in choosing appropriate empirical antimicrobial therapy.


2021 ◽  
Vol 10 (1) ◽  
Author(s):  
Assaf Ben Shoham ◽  
Gabriel Munter

Abstract Background Emergency department overcrowding is associated with adverse clinical outcomes and poor patients and staff experience. Full capacity protocols enabling hallway boarding in internal wards are instituted to relieve emergency room overcrowding. The effect of hallway boarding on the clinical outcomes of all inpatients in the internal wards has not been studied. Early in 2016, a decision to enable hallway boarding in the internal wing in our medical center came into effect, comprising an abrupt change to the medical center’s policy. The objective of this study is to examine the effect of hallway boarding on patients who were hospitalized in the internal wards. Methods General linear regression analysis, based on administrative data about admissions of patients, from January 2013 through September 2019, is used to compare in-hospital mortality, 30-day readmission and 30-day mortality rates, of inpatients hospitalized in two internal departments in our medical center, before and after the policy change. Results Eight thousand five hundred eighty-three patients and 11,962 patients were admitted to internal departments A and B, before and after the policy change, respectively. Adjusted in-hospital mortality was lower after the policy change (OR 0.76, [CI, 0.65 to 0.90]), 30-day readmission was mildly higher (OR, 1.18 [CI, 1.00 to 1.40]) and no change in 30-day mortality was observed (OR 1.16 [CI, 0.88 to 1.53]). The results emanate from corresponding changes in department A. No apparent change was observed in the length of hospital stay in department A, while a shorter length of stay was observed in department B. Conclusion Enabling inpatient boarding in our medical center, effectively, had increased bed capacity and generated an increase in the volume of patients. It was associated with lower in-hospital mortality and an increased 30-day readmission, without increasing 30-day mortality. Since this is an observational study, conducted in a single center, further research is necessary to confirm and qualify these observations.


2016 ◽  
Vol 51 (1) ◽  
pp. 13-20 ◽  
Author(s):  
Janet Y. Wu ◽  
Joanna L. Stollings ◽  
Arthur P. Wheeler ◽  
Matthew W. Semler ◽  
Todd W. Rice

Background: In septic shock, the dose of norepinephrine (NE) at which vasopressin (AVP) should be added is unknown. Following an increase in AVP price, our medical intensive care unit (MICU) revised its vasopressor guidelines to reserve AVP for patients requiring greater than 50 µg/min of NE. Objective: The purpose of this study is to compare efficacy and safety outcomes for patients admitted before the guideline revision with those for patients admitted after the revision. Methods: This was a single-center, retrospective cohort study of patients admitted to Vanderbilt University Medical Center from November 1, 2014, to November 30, 2015. Before June 1, 2015, the vasopressor guidelines recommended initiation of AVP for patients requiring 10 µg/min of NE or greater. After June 1, 2015, the guidelines recommended initiation of AVP at a NE dose of 50 µg/min or greater. Results: Time to achieve goal mean arterial pressure (MAP) was shorter in the postintervention group (2.0 vs 1.3 hours; P = 0.03) in univariate analysis but not after adjusting for prespecified confounders. Incidence of new arrhythmias was similar between the 2 groups (14.9% vs 10.9%; P = 0.567). In multivariable analysis accounting for baseline severity of illness, admission after the revision was associated with decreased 28-day mortality (odds ratio = 0.34; 95% CI = 0.16-0.71; P = 0.004). Conclusions: Use of a vasopressor guideline restricting AVP initiation in septic patients to those on at least 50 µg/min of NE appeared to be safe and did not affect the time to reach goal MAP.


2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S116-S117
Author(s):  
Shelbye R Herbin ◽  
Marco R Scipione ◽  
Raymond Yost

Abstract Background The Drug Resistance in Pneumonia (DRIP) score is a predictive model for identifying drug-resistant pathogens in community-acquired pneumonia (CAP). The Detroit Medical Center adopted DRIP documentation at time of antimicrobial order entry for CAP in 2017. The purpose of this study was to identify the difference in overall consumption of antibiotics used for the treatment of CAP after the implementation of DRIP documentation. Methods A retrospective analysis of adult patients with an antimicrobial order with a documented indication of pneumonia between Jun 1-Oct 31, 2017 and Jun 1-Oct 31, 2018, was conducted. Days of antimicrobial therapy per 1000 adjusted patient days (DOT/1000 pt days) was assessed in patients before and after implementation of DRIP documentation at time of order entry. The percent concordance with institutional guidelines for empiric CAP treatment post-implementation of DRIP documentation was also evaluated. Results The DOT/1000 pt days increased in the post-DRIP group for ceftriaxone (36.5 vs. 76.3), doxycycline (22.3 vs. 44.5), and azithromycin (29.5 vs. 53.4). The DOT/1000 pt days decreased for carbapenems in the post-DRIP group (14.0 vs. 8.5). There was no change in vancomycin or linezolid use. Empiric therapy after implementation of DRIP documentation was concordant with institutional guidelines in 34.7% and 11.2% of patients with documented DRIP&lt; 4 and DRIP≥4, respectively. Overall, the most common reason for non-concordance was lack of atypical coverage. Use of expanded Gram-negative coverage (i.e. cefepime) for documented DRIP&lt; 4, and lack of expanded Gram-negative coverage with aminoglycosides in ICU patients with documented DRIP≥4 were also common Conclusion An increase in guideline-directed therapy and a decrease in use of carbapenems were seen after implementation of DRIP score documentation at time of order entry. Overall concordance with guidelines was low, and additional review is needed to identify if providers are accurately documenting the DRIP score. Future directions should focus on education of clinicians on the importance of accurate DRIP documentation in order to improve compliance with institutional guidelines. Disclosures All Authors: No reported disclosures


2017 ◽  
Vol 10 (2) ◽  
pp. 113-120
Author(s):  
Dianne Lavin ◽  
Justin White ◽  
Martha Medrano ◽  
Amy Ranieri

This project explored the effect of an automated appointment reminder system (texts/e-mails/telephone calls) on patient attendance at behavioral health appointments in a federally qualified health care agency in Texas. Appointment reminder systems have been shown to improve attendance rates in behavioral health (Clouse, Williams, & Harmon, 2017; Gajwani, 2014; Molfenter, 2013; Whisenhunt, 2014). It was expected that behavioral appointment attendance which in this agency has been historically low, would increase following implementation of an automated appointment reminder system. A retrospective electronic health record review was completed to compare behavioral health appointment attendance rates before and after implementation of an automated appointment reminder system. Data analysis revealed that no-show rates for behavioral health appointments in the previous appointment reminder system (telephone call reminders) and the recently implemented automated appointment reminder system (texts/e-mails/telephone calls) were comparable with rates of 19.4% and 20.0%, respectively. The difference between the rates was not statistically significant suggesting that the automated appointment reminder system was not effective in improving patient attendance at behavioral health appointments.


2019 ◽  
Vol 10 (05) ◽  
pp. 849-858
Author(s):  
Benjamin R. Kummer ◽  
Joshua Z. Willey ◽  
Michael J. Zelenetz ◽  
Yiping Hu ◽  
Soumitra Sengupta ◽  
...  

Abstract Background Neurologists perform a significant amount of consultative work. Aggregative electronic health record (EHR) dashboards may help to reduce consultation turnaround time (TAT) which may reflect time spent interfacing with the EHR. Objectives This study was aimed to measure the difference in TAT before and after the implementation of a neurological dashboard. Methods We retrospectively studied a neurological dashboard in a read-only, web-based, clinical data review platform at an academic medical center that was separate from our institutional EHR. Using our EHR, we identified all distinct initial neurological consultations at our institution that were completed in the 5 months before, 5 months after, and 12 months after the dashboard go-live in December 2017. Using log data, we determined total dashboard users, unique page hits, patient-chart accesses, and user departments at 5 months after go-live. We calculated TAT as the difference in time between the placement of the consultation order and completion of the consultation note in the EHR. Results By April 30th in 2018, we identified 269 unique users, 684 dashboard page hits (median hits/user 1.0, interquartile range [IQR] = 1.0), and 510 unique patient-chart accesses. In 5 months before the go-live, 1,434 neurology consultations were completed with a median TAT of 2.0 hours (IQR = 2.5) which was significantly longer than during 5 months after the go-live, with 1,672 neurology consultations completed with a median TAT of 1.8 hours (IQR = 2.2; p = 0.001). Over the following 7 months, 2,160 consultations were completed and median TAT remained unchanged at 1.8 hours (IQR = 2.5). Conclusion At a large academic institution, we found a significant decrease in inpatient consult TAT 5 and 12 months after the implementation of a neurological dashboard. Further study is necessary to investigate the cognitive and operational effects of aggregative dashboards in neurology and to optimize their use.


2020 ◽  
Vol 41 (S1) ◽  
pp. s230-s231
Author(s):  
Emily Min ◽  
Timileyin Adediran ◽  
Kerri Thom ◽  
Emily Heil

Background: In October 2013, the University of Maryland Medical Center established a formal antibiotic prophylaxis protocol for patients undergoing ventricular assist device (VAD) placement, replacing a previous system of various broad-spectrum antibiotic combinations typically for prolonged durations based on surgeon preference. This new protocol consisted of a standardized regimen of 72 hours of vancomycin and ceftriaxone after the procedure. The objective of this project was to evaluate the rate of surgical site infection (SSI) related to VAD placement to ensure that implementing the new protocol did not cause an increase in SSI rates. Methods: The study was a retrospective cohort study of patients who had undergone VAD placement before the protocol change (January 1, 2011, to October 1, 2013) and after the change (October 1, 2013, to November 15, 2015). The primary outcomes was the difference in SSI rate before and after the protocol change using CDC NHSN definitions. Pertinent data points of interest included reason for VAD placement, duration/type of antibiotics used, delayed sternal closure, SSI, characterization of infection (bloodstream, driveline, or pocket), organism identified on culture and mortality at 30 days and 1 year. SSI rates were assessed using the Fischer exact test, and descriptive statistics were used for other outcome variables. Results: In total, 75 patients were included before the protocol and 46 after the protocol change. Overall, 27% and 17% of patients were on therapeutic antibiotics prior to the VAD placement, respectively (P = 0.23). Also, 8 (6.6%) patients in the preintervention group had an SSI compared to 1 patient (0.8%) in the postintervention group (P = .15). Adherence to the protocol was suboptimal, with 27% of patients in the postintervention group receiving non–protocol-adherent antibiotics and 65% of patients receiving antibiotics >96 hours postoperatively. When evaluating the patients collectively, SSI rates were the same when antibiotics were discontinued <72 hours postoperatively versus when antibiotics were continued beyond 72 hours postoperatively or were not given at all postoperatively (3.1% vs 10.7% vs 0%; P = .24). SSI rates were also no different among patients who received cefazolin monotherapy (0%), vancomycin and ceftriaxone (2.7%), vancomycin and piperacillin tazobactam (2%), and other antibiotic combinations (7.7%) for surgical prophylaxis (P = 0.1). Conclusions: No change in SSI rates was noted after a protocol change narrowing the spectrum and duration of antibiotic prophylaxis was implemented. Evaluation of optimal surgical prophylaxis in this patient population is difficult due to low event rates and frequent therapeutic indications for antibiotics outside the standard prophylaxis. Despite these challenges, this study supports the safety of studying SSI prophylaxis reduction in the VAD population. Further studies are reasonable and warranted.Funding: NoneDisclosures: None


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