scholarly journals Early abolition of cough reflex predicts mortality in deeply sedated brain-injured patients

PeerJ ◽  
2020 ◽  
Vol 8 ◽  
pp. e10326
Author(s):  
Stanislas Kandelman ◽  
Jérémy Allary ◽  
Raphael Porcher ◽  
Cássia Righy ◽  
Clarissa Francisca Valdez ◽  
...  
Keyword(s):  
Intensive Care ◽  
Deep Sedation ◽  
Simplified Acute Physiology Score ◽  
Sedation Scale ◽  
Neurological Assessment ◽  
Multicenter Cohort Study ◽  
Cough Reflex ◽  
Saps Ii ◽  
Brain Injured ◽  
Injured Patients

Background Deep sedation may hamper the detection of neurological deterioration in brain-injured patients. Impaired brainstem reflexes within the first 24 h of deep sedation are associated with increased mortality in non-brain-injured patients. Our objective was to confirm this association in brain-injured patients. Methods This was an observational prospective multicenter cohort study involving four neuro-intensive care units. We included acute brain-injured patients requiring deep sedation, defined by a Richmond Assessment Sedation Scale (RASS) < −3. Neurological assessment was performed at day 1 and included pupillary diameter, pupillary light, corneal and cough reflexes, and grimace and motor response to noxious stimuli. Pre-sedation Glasgow Coma Scale (GCS) and Simplified Acute Physiology Score (SAPS-II) were collected, as well as the cause of death in the Intensive Care Unit (ICU). Results A total of 137 brain-injured patients were recruited, including 70 (51%) traumatic brain-injured patients, 40 (29%) vascular (subarachnoid hemorrhage or intracerebral hemorrhage). Thirty patients (22%) died in the ICU. At day 1, the corneal (OR 2.69, p = 0.034) and cough reflexes (OR 5.12, p = 0.0003) were more frequently abolished in patients that died in the ICU. In a multivariate analysis, abolished cough reflex was associated with ICU mortality after adjustment to pre-sedation GCS, SAPS-II, RASS (OR: 5.19, 95% CI [1.92–14.1], p = 0.001) or dose of sedatives (OR: 8.89, 95% CI [2.64–30.0], p = 0.0004). Conclusion Early (day 1) cough reflex abolition is an independent predictor of mortality in deeply sedated brain-injured patients. Abolished cough reflex likely reflects a brainstem dysfunction that might result from the combination of primary and secondary neuro-inflammatory cerebral insults revealed and/or worsened by sedation.

scholarly journals A gap existed between physicians’ perceptions and performance of pain, agitation-sedation and delirium assessments in Chinese intensive care units

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Kai Chen ◽  
Yan-Lin Yang ◽  
Hong-Liang Li ◽  
Dan Xiao ◽  
Yang Wang ◽  
...  
Keyword(s):  
Critical Care ◽  
Intensive Care ◽  
Intensive Care Units ◽  
Clinical Performance ◽  
Sedation Scale ◽  
Delirium Assessment ◽  
Brain Injured ◽  
Delirium Management ◽  
And Performance ◽  
Injured Patients

Abstract Background Pain, agitation-sedation and delirium management are crucial elements in the care of critically ill patients. In the present study, we aimed to present the current practice of pain, agitation-sedation and delirium assessments in Chinese intensive care units (ICUs) and investigate the gap between physicians’ perception and actual clinical performance. Methods We sent invitations to the 33 members of the Neuro-Critical Care Committee affiliated with the Chinese Association of Critical Care Physicians. Finally, 24 ICUs (14 general-, 5 neuroscience-, 3 surgical-, and 2 emergency-ICUs) from 20 hospitals participated in this one-day point prevalence study combined with an on-site questionnaire survey. We enrolled adult ICU admitted patients with a length of stay ≥24 h, who were divided into the brain-injured group or non-brain-injured group. The hospital records and nursing records during the 24-h period prior to enrollment were reviewed. Actual evaluations of pain, agitation-sedation and delirium were documented. We invited physicians on-duty during the 24 h prior to the patients’ enrollment to complete a survey questionnaire, which contained attitude for importance of pain, agitation-sedation and delirium assessments. Results We enrolled 387 patients including 261 (67.4%) brain-injured and 126 (32.6%) non-brain-injured patients. There were 19.9% (95% confidence interval [CI]: 15.9–23.9%) and 25.6% (95% CI: 21.2–29.9%) patients receiving the pain and agitation-sedation scale assessment, respectively. The rates of these two types of assessments were significantly lower in brain-injured patients than non-brain-injured patients (p = 0.003 and < 0.001). Delirium assessment was only performed in three patients (0.8, 95% CI: 0.1–1.7%). In questionnaires collected from 91 physicians, 70.3% (95% CI: 60.8–79.9%) and 82.4% (95% CI: 74.4–90.4%) reported routine use of pain and agitation-sedation scale assessments, respectively. More than half of the physicians (52.7, 95% CI: 42.3–63.2%) reported daily screening for delirium using an assessment scale. Conclusions The actual prevalence of pain, agitation-sedation and delirium assessment, especially delirium screening, was suboptimal in Chinese ICUs. There is a gap between physicians’ perceptions and actual clinical practice in pain, agitation-sedation and delirium assessments. Our results will prompt further quality improvement projects to optimize the practice of pain, agitation-sedation and delirium management in China. Trial registration ClinicalTrials.gov, identifier NCT03975751. Retrospectively registered on 2 June 2019.

scholarly journals The Pros and Cons of the Prediction Game: The Never-ending Debate of Mortality in the Intensive Care Unit

2019 ◽  
Vol 16 (18) ◽  
pp. 3394 ◽  
Author(s):  
Piotr A. Fuchs ◽  
Iwona J. Czech ◽  
Łukasz J. Krzych
Keyword(s):  
Intensive Care ◽  
Scoring Systems ◽  
Roc Curves ◽  
Simplified Acute Physiology Score ◽  
Apache Ii ◽  
Icu Mortality ◽  
Saps Ii ◽  
Icu Discharge ◽  
Pros And Cons ◽  
Long Term Prognosis

Background: The Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and Sequential Organ Failure Assessment (SOFA) scales are scoring systems used in intensive care units (ICUs) worldwide. We aimed to investigate their usefulness in predicting short- and long-term prognosis in the local ICU. Methods: This single-center observational study covered 905 patients admitted from 1 January 2015 to 31 December 2017 to a tertiary mixed ICU. SAPS II, APACHE II, and SOFA scores were calculated based on the worst values from the first 24 h post-admission. Patients were divided into surgical (SP) and nonsurgical (NSP) subjects. Unadjusted ICU and post-ICU discharge mortality rates were considered the outcomes. Results: Baseline SAPS II, APACHE II, and SOFA scores were 41.1 ± 20.34, 14.07 ± 8.73, and 6.33 ± 4.12 points, respectively. All scores were significantly lower among SP compared to NSP (p < 0.05). ICU mortality reached 35.4% and was significantly lower for SP (25.3%) than NSP (57.9%) (p < 0.001). The areas under the receiver-operating characteristic (ROC) curves were 0.826, 0.836, and 0.788 for SAPS II, APACHE II, and SOFA scales, respectively, for predicting ICU prognosis, and 0.708, 0.709, and 0.661 for SAPS II, APACHE II, and SOFA, respectively, for post-ICU prognosis. Conclusions: Although APACHE II and SAPS II are good predictors of ICU mortality, they failed to predict survival after discharge. Surgical patients had a better prognosis than medical ICU patients.

scholarly journals Outcome of Patients With Necrotizing Vasculitis Admitted to the Intensive Care Unit (ICU) for Sepsis: Results of a Single-Centre Retrospective Analysis

2020 ◽  
pp. 088506662095376
Author(s):  
Marco Krasselt ◽  
Christoph Baerwald ◽  
Sirak Petros ◽  
Olga Seifert
Keyword(s):  
Intensive Care Unit ◽  
Logistic Regression ◽  
Intensive Care ◽  
Tertiary Hospital ◽  
Simplified Acute Physiology Score ◽  
Apache Ii ◽  
Necrotizing Vasculitis ◽  
Multivariate Logistic Regression ◽  
Sepsis Mortality ◽  
Saps Ii

Introduction/Background: Vasculitis patients have a high risk for infections that may require intensive care unit (ICU) treatment in case of resulting sepsis. Since data on sepsis mortality in this patient group is limited, the present study investigated the clinical characteristics and outcomes of vasculitis patients admitted to the ICU for sepsis. Methods: The medical records of all necrotizing vasculitis patients admitted to the ICU of a tertiary hospital for sepsis in a 13-year period have been reviewed. Mortality was calculated and multivariate logistic regression was used to determine independent risk factors for sepsis mortality. Moreover, the predictive power of common ICU scores was further evaluated. Results: The study included 34 patients with necrotizing vasculitis (mean age 69 ± 9.9 years, 35.3% females). 47.1% (n = 16) were treated with immunosuppressives (mostly cyclophosphamide, n = 35.3%) and 76.5% (n = 26) received glucocorticoids. Rituximab was used in 4 patients (11.8%).The in-hospital mortality of septic vasculitis patients was 41.2%. The Sequential Organ Failure Assessment (SOFA) score (p = 0.003) was independently associated with mortality in multivariate logistic regression. Acute Physiology And Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II) and SOFA scores were good predictors of sepsis mortality in the investigated vasculitis patients (APACHE II AUC 0.73, p = 0.02; SAPS II AUC 0.81, p < 0.01; SOFA AUC 0.898, p < 0.0001). Conclusions: Sepsis mortality was high in vasculitis patients. SOFA was independently associated with mortality in a logistic regression model. SOFA and other well-established ICU scores were good mortality predictors.

scholarly journals Performance of Sequential Organ Failure Assessment and Simplified Acute Physiology Score II for Post-Cardiac Surgery Patients in Intensive Care Unit

2021 ◽  
Vol 8 ◽  
Author(s):  
Fei Xu ◽  
Weina Li ◽  
Cheng Zhang ◽  
Rong Cao
Keyword(s):  
Cardiac Surgery ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Hospital Stay ◽  
Scoring System ◽  
Simplified Acute Physiology Score ◽  
Saps Ii ◽  
Icu Stay ◽  
Cutoff Values ◽  
Adjusted Model

Background: The aim of this study is to assess the performance of Sequential Organ Failure Assessment (SOFA) score and Simplified Acute Physiology Score (SAPS II) on outcomes of patients with cardiac surgery and identify the cutoff values to provide a reference for early intervention.Methods: All data were extracted from MIMIC-III (Medical Information Mart for Intensive Care-III) database. Cutoff values were calculated by the receiver-operating characteristic curve and Youden indexes. Patients were grouped, respectively, according to the cutoff values of SOFA and SAPS II. A non-adjusted model and adjusted model were established to evaluate the prediction of risk. Comparison of clinical efficacy between two scoring systems was made by decision curve analysis (DCA). The primary outcomes of this study were in-hospital mortality, 28-day mortality, 90-day mortality, and 1-year mortality after cardiac surgery. The secondary outcomes included length of hospital stay and intensive care unit (ICU) stay and the incidence of acute kidney injury (AKI) within 7 days after ICU admission.Results: A total of 6,122 patients were collected and divided into the H-SOFA group (SOFA ≥ 7) and L-SOFA group (SOFA &lt; 7) or H-SAPS II group (SAPS II ≥ 43) and L-SAPS II group (SAPS II &lt; 43). In-hospital mortality, 28-day mortality, 90-day mortality, and 1-year mortality were higher, the length of hospital and ICU stay were longer in the H-SOFA group than in the L-SOFA group (p &lt; 0.05), while the incidence of AKI was not significantly different. In-hospital mortality, 28-day mortality, 90-day mortality, 1-year mortality, and the incidence of AKI were all significantly higher in the H-SAPS II group than in the L-SAPS II group (p &lt; 0.05). Hospital stay and ICU stay were longer in the H-SAPS II group than in the L-SAPS II group (p &lt; 0.05). According to DCA, the SAPS II scoring system had more net benefits on assessing the long-term mortality compared with the SOFA scoring system.Conclusion: Exceeding the cutoff values of SOFA and SAPS II scores could lead to increased mortality and extended length of ICU and hospital stay. The SAPS II scoring system had a better discriminative performance of 90-day mortality and 1-year mortality in post-cardiac surgery patients than the SOFA scoring system. Emphasizing the critical value of the scoring system is of significance for timely treatment.

Prognostic Factors for Neutropenic Patients Admitted to Intensive Care.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 3900-3900
Author(s):  
Madalena Silva ◽  
Luisa Checa ◽  
Fatima Costa ◽  
Rui Moreno ◽  
Eduardo G. Silva ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Underlying Disease ◽  
Simplified Acute Physiology Score ◽  
Prognostic Impact ◽  
Saps Ii ◽  
Severity Scores ◽  
Saps Ii Score ◽  
Organ Failures ◽  
Neutropenic Patients

Abstract The admission of neutropenic patients (pts) to intensive care units (ICU) is controversial, especially when mechanical ventilation is required. Knowledge of the relative prognostic impact of factors related to the underlying disease and to the severity of acute organ failures might help avoiding futile admissions. We retrospectively assessed predictors of 30-day mortality in neutropenic (&lt;1000/ul) pts referred from a single Hematology unit to the 2 ICUs of the institution over a 10-year period. Of 66 consecutive pts, median age 48 (15–73), 82% had acute leukemia (AL) and 21% were in complete remission (CR). On ICU admission 62% of the pts had a neutrophil count ≤500/ul; microbiologically documented infection was found in 42%. The main reason for ICU referral was severe sepsis or septic shock in 62% of the cases and respiratory failure in 38%. Seventy per cent of the pts were already on vasopressor agents. At ICU entry the median Simplified Acute Physiology Score (SAPS) II was 63 and 26% of pts had ≥ 2 acute organ system failures (OSF). Coma was present in 23%. Mechanical ventilation was eventually needed in 89% and dialysis in 9% of the pts. Mortality at 30 days was 73%. By univariate logistic regression analysis mortality was not significantly related to age, to status of underlying disease (CR vs no CR/not yet known) to duration of neutropenia nor to depth of neutropenia at entry (≤ 500 vs &gt;500/ul). Pts who died were more likely to have non-M3 AL subtype vs M3 (p=0.037), to have ≥ 2 acute OSF vs &lt; 2 (p=0.012) and a higher SAPS II score (p&lt; 0.001). In multivariate analysis only the latter 2 variables remained significant. In conclusion, our data show that 27% of neutropenic pts admitted to ICUs are alive at 30 days; that selection for admission should not be based on the characteristics of the underlying malignancy; and that the 30-day mortality is highly predictable by initial acute illness severity scores.

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