Incidence and Risk Factors of Ventilator-Associated Pneumonia among Patients with Delirium in the Intensive Care Unit: A Prospective Observational Study

Introduction. The incidence and risk factors for ventilator-related pneumonia (VAP) in patients with delirium are deficient, and there is a lack of in-depth knowledge of the impact of VAP on outcomes in this population. We investigated the incidence, risk factors, and outcomes of VAP in patients with delirium. Materials and Methods. This prospective observational study was performed in a surgical ICU at Be’sat Hospital in Hamadan, Iran, between 2018 and 2019. A total of 108 patients with delirium were identified using the Confusion Assessment Method (CAM) for the ICU and Intensive Care Delirium Screening Checklist (ICDSC) and enrolled in this study. The association between VAP and delirium, risk factors, and outcomes (ICU length of stay and ICU mortality) for VAP were investigated using the Cox proportional hazards model and logistic and simple linear regression analyses with a 95% confidence interval. Results. Of 108 delirium patients, 86 patients (79.6%) underwent mechanical ventilation (MV) and 16 patients (18.6%) experienced VAP during ICU stay. The median onset of VAP was 6.5 (IQR 4.2–7.7) days after intubation. Delirium patients with VAP stayed longer in the ICU (21.68 ± 4.26 vs.12.93 ± 1.71, P < 0.001 ) and also had higher ICU mortality (31.25% vs. 0%, P < 0.001 ) than subjects without VAP. According to multivariate cox regression, the expected HR for VAP was 53.5% lower for patients with early-onset delirium than in patients with late-onset delirium (HR: 0.465, 95% CI: 0.241–0.894, P = 0.022 ). However, the expected hazard for VAP was 1.854 times and 4.604 times higher in patients with longer ICU stay (HR: 1.854, 95% CI: 1.689–3.059, P = 0.032 ) and in patients with a prolonged MV duration (HR: 4.604, 95%CI: 1.567–6.708, P = 0.023 ). Conclusion. According to the results, there seems to be an inverse relationship between early onset of delirium and VAP. This finding cannot be conclusively cited, and more studies in this filed should be conducted with a larger sample size. Furthermore, VAP in delirium patients is associated with increases in poor outcomes (higher ICU mortality) and the use of medical resources (longer stay in the ICU and MV duration).

Early Measurement of ROX Index in Intermediary Care Unit Is Associated with Mortality in Intubated COVID-19 Patients: A Retrospective Study

COVID-19 patients often present with rapidly progressing acute hypoxemic respiratory failure, requiring orotracheal intubation with different prognostic issues. However, ICU specialists lack predictive tools to stratify these patients. We conducted a single-center cross-sectional retrospective study to evaluate if the ROX index, measured under non-invasive oxygenation support, can predict ICU mortality in a COVID-19 intubated patient cohort. This study took place in the division of intensive care at the Geneva University Hospitals (Geneva, Switzerland). We included all consecutive adult patients treated by non-invasive oxygenation support and requiring intubation for acute respiratory failure due to COVID-19 between 9 September 2020 and 30 March 2021, corresponding to the second local surge of COVID-19 cases. Baseline demographic data, comorbidities, median ROX between H0 and H8, and clinical outcomes were collected. Overall, 82 patients were intubated after failing a non-invasive oxygenation procedure. Women represented 25.6% of the whole cohort. Median age and median BMI were 70 (60–75) years and 28 (25–33), respectively. Before intubation, the median ROX between H0 and H8 was 6.3 (5.0–8.2). In a multivariate analysis, the median ROX H0–H8 was associated with ICU mortality as a protective factor with an odds ratio (95% CI) = 0.77 (0.60–0.99); p < 0.05. In intubated COVID-19 patients treated initially by non-invasive oxygenation support for acute respiratory failure, the median ROX H0–H8 could be an interesting predictive factor associated with ICU mortality.

Pulmonary Hypertension at Admission predicts ICU Mortality in Elderly Critically ill with Severe COVID-19 Pneumonia: retrospective cohort study

BackgroundPoint-of-care ultrasound (POCUS) is a useful diagnostic tool for non-invasive assessment of critically ill patients. Mortality of elderly patients with COVID-19 pneumonia is high and there is still scarcity of definitive predictors. Aim of our study was to assess the prediction value of combined lung and heart POCUS data on mortality of elderly critically ill patients with severe COVID-19 pneumonia.MethodsThis was a retrospective observational study. Data of patients older than 70 years, with severe COVID-19 pneumonia admitted to 25-bed mixed, level 3, intensive care unit (ICU) was analyzed retrospectively. POCUS was performed at admission; our parameters of interest were pulmonary artery systolic pressure (PASP) and presence of diffuse B-line pattern (B-pattern) on lung ultrasound.ResultsBetween March 2020 and February 2021, 117 patients aged 70 years or more (average age 77±5 years) were included. Average length of ICU stay was 10.7±8.9 days. High-flow oxygenation, non-invasive ventilation and invasive mechanical ventilation were at some point used to support 36/117 (31%), 39/117 (33%) and 75/117 (64%) patients respectively. ICU mortality was 50.9%. ICU stay was shorter in survivors (8.8±8.3 vs 12.6±9.3 days, p=0.02). PASP was lower in ICU survivors (32.5±9.8 vs. 40.4±14.3 mmHg, p=0.024). B-pattern was more often detected in non-survivals (35/59 (59%) vs. 19/58 (33%), p=0.005). PASP and B-pattern at admission were both univariate predictors of mortality. PASP at admission was an independent predictor of ICU (OR 1.0683, 95%CI: 1.0108-1.1291, p=0.02) and hospital (OR 1.0813, 95%CI 1.0125-1.1548, p=0.02) mortality. Ventilator associated pneumonia (VAP) was a strong predictor of ICU and hospital mortality.ConclusionsPASP at admission is an independent predictor of ICU and hospital mortality of elderly patients with severe COVID-19 pneumonia. During ICU stay development of VAP was a strong predictor of ICU and hospital mortality.

Prone positioning during venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a pooled individual patient data analysis

Background Prone positioning (PP) reduces mortality of patients with acute respiratory distress syndrome (ARDS). The potential benefit of prone positioning maneuvers during venovenous extracorporeal membrane oxygenation (ECMO) is unknown. The aim of this study was to evaluate the association between the use of prone positioning during extracorporeal support and ICU mortality in a pooled population of patients from previous European cohort studies. Methods We performed a pooled individual patient data analysis of European cohort studies which compared patients treated with prone positioning during ECMO (Prone group) to “conventional” ECMO management (Supine group) in patients with severe ARDS. Results 889 patients from five studies were included. Unadjusted ICU mortality was 52.8% in the Supine Group and 40.8% in the Prone group. At a Cox multiple regression analysis PP during ECMO was not significantly associated with a reduction of ICU mortality (HR 0.67 95% CI: 0.42–1.06). Propensity score matching identified 227 patients in each group. ICU mortality of the matched samples was 48.0% and 39.6% for patients in the Supine and Prone group, respectively (p = 0.072). Conclusions In a large population of ARDS patients receiving venovenous extracorporeal support, the use of prone positioning during ECMO was not significantly associated with reduced ICU mortality. The impact of this procedure will have to be definitively assessed by prospective randomized controlled trials.

A ten-year review of indications and outcomes of obstetric admissions to an intensive care unit in a low-resource country

Introduction Obstetric intensive care unit admission (ICU) suggests severe morbidity. However, there is no available data on the subject in Ghana. This retrospective review was conducted to determine the indications for obstetric ICU admission, their outcomes and factors influencing these outcomes to aid continuous quality improvement in obstetric care. Methods This was a retrospective review conducted in a tertiary hospital in Ghana. Data on participant characteristics including age and whether participant was intubated were collected from patient records for all obstetric ICU admissions from 1st January 2010 to 31st December 2019. Descriptive statistics were presented as frequencies, proportions and charts. Hazard ratios were generated for relations between obstetric ICU admission outcome and participant characteristics. A p-value <0.05 was deemed statistically significant. Results There were 443 obstetric ICU admissions over the review period making up 25.7% of all ICU admissions. The commonest indications for obstetric ICU admissions were hypertensive disorders of pregnancy (70.4%, n = 312/443), hemorrhage (14.4%, n = 64/443) and sepsis (9.3%, n = 41/443). The case fatality rates for hypertension, hemorrhage, and sepsis were 17.6%, 37.5%, and 63.4% respectively. The obstetric ICU mortality rate was 26% (115/443) over the review period. Age ≥25 years and a need for mechanical ventilation carried increased mortality risks following ICU admission while surgery in the index pregnancy was associated with a reduced risk of death. Conclusion Hypertension, haemorrhage and sepsis are the leading indications for obstetric ICU admissions. Thus, preeclampsia screening and prevention, as well as intensifying antenatal education on the danger signs of pregnancy can minimize obstetric complications. The establishment of an obstetric HDU in CCTH and the strengthening of communication between specialists and the healthcare providers in the lower facilities, are also essential for improved pregnancy outcomes. Further studies are needed to better appreciate the wider issues underlying obstetric ICU admission outcomes. Plain language summary This was a review of the reasons for admitting severely-ill pregnant women and women who had delivered within the past 42 days to the intensive care unit (ICU), the admission outcomes and risk factors associated with ICU mortality in a tertiary hospital in a low-resource country. High blood pressure and its complications, bleeding and severe infections were observed as the three most significant reasons for ICU admissions in decreasing order of significance. Pre-existing medical conditions and those arising as a result of, or aggravated by pregnancy; obstructed labour and post-operative monitoring were the other reasons for ICU admission over the study period. Overall, 26% of the admitted patients died at the ICU and maternal age of at least 25 years and the need for intubation were identified as risk factors for ICU deaths. Attention must be paid to high blood pressure during pregnancy.

A Comparison between Continuous Indirect Calorimetry and Single Weight-Based Formula in Estimating Resting Energy Expenditure in Nutritional Therapy: A Prospective Randomized Controlled Study in Critically Ill Patients

Optimal nutritional therapy is important to improve outcome in critically ill population in an intensive care unit (ICU). Although indirect calorimetry (IC) is currently a gold standard for resting energy expenditure (REE) measurement, yet it is still not routinely used in the ICU. A total of 146 mechanically ventilated patients were randomised to receive enteral nutrition (EN) with energy targeted based on continuous indirect calorimetry (IC) measurements (IC group, n=73) or according to 25 kcal/kg/day (SWB group, n=73). Patient characteristics were equally distributed and the IC group showed lower mean measured REE (1668.1 + 231.7 vs 1512.0 + 177.1 kcal, p<0.001). Results also showed a significant deficiency in the daily (-148.8 + 105.1 vs. -4.99 + 44.0 kcal, p<0.001) and total cumulative energy balances (-1165.3 + 958.1 vs. 46.5 + 369.5 kcal, p<0.001) in the SWB group as compared to the IC group. From the Kaplan-Meier survival analysis, we found that ICU mortality was significantly lower in the IC group with better survival probability compared to the SWB group (log-rank test, p = 0.03). However, both groups showed comparable results in terms of ICU length of stay, duration of mechanical ventilation and incidence of feeding intolerance. In conclusion, this study showed that tightly supervised nutritional therapy based on continuous IC measurement provides significantly less mean daily and cumulative energy deficits as well as significantly reduced ICU mortality rate.

Association of Prior to Intensive Care Unit Statin Use With Outcomes on Patients With Acute Kidney Injury

Purpose: To evaluate the association of prior to intensive care unit (ICU) statin use with the clinical outcomes in critically ill patients with acute kidney injury (AKI).Materials and Methods: Patients with AKI were selected from the Medical Information Mart for Intensive Care IV (version 1.0) database for this retrospective observational study. The primary outcome was 30-day intensive care unit (ICU) mortality. A 30-day in-hospital mortality and ICU length of stay (LOS) were considered as secondary outcomes. Comparison of mortality between pre-ICU statin users with non-users was conducted by the multivariate Cox proportional hazards model. Comparison of ICU LOS between two groups was implemented by multivariate linear model. Three propensity score methods were used to verify the results as sensitivity analyses. Stratification analyses were conducted to explore whether the association between pre-ICU statin use and mortality differed across various subgroups classified by sex and different AKI stages.Results: We identified 3,821 pre-ICU statin users and 9,690 non-users. In multivariate model, pre-ICU statin use was associated with reduced 30-day ICU mortality rate [hazard ratio (HR) 0.68 (0.59, 0.79); p &lt; 0.001], 30-day in-hospital mortality rate [HR 0.64 (0.57, 0.72); p &lt; 0.001] and ICU LOS [mean difference −0.51(−0.79, −0.24); p &lt; 0.001]. The results were consistent in three propensity score methods. In subgroup analyses, pre-ICU statin use was associated with decreased 30-day ICU mortality and 30-day in-hospital mortality in both sexes and AKI stages, except for 30-day ICU mortality in AKI stage 1.Conclusion: Patients with AKI who were administered statins prior to ICU admission might have lower mortality during ICU and hospital stay and shorter ICU LOS.

CytoSorb Therapy in COVID-19 (CTC) Patients Requiring Extracorporeal Membrane Oxygenation: A Multicenter, Retrospective Registry

Introduction: CytoSorb extracorporeal blood purification therapy received FDA Emergency Use Authorization (EUA) to suppress hyperinflammation in critically ill COVID-19 patients. The multicenter CTC Registry was established to systematically collect patient-level data, outcomes, and utilization patterns of CytoSorb under the EUA.Methods: Patient-level data was entered retrospectively at participating centers. The primary outcome of the registry was ICU mortality. Patient disposition of death, continuing ICU care, or ICU discharge was analyzed up to Day 90 after start of CytoSorb therapy. Demographics, comorbidities, COVID-19 medications, inflammatory biomarkers, and details on CytoSorb use were compared between survivors and non-survivors in the veno-venous extracorporeal membrane oxygenation (ECMO) cohort.Results: Between April 2020 and April 2021, 52 patients received veno-venous ECMO plus CytoSorb therapy at 5 U.S. centers. ICU mortality was 17.3% (9/52) on day 30, 26.9% (14/52) on day 90, and 30.8% (16/52) at final follow-up of 153 days. Survivors had a trend toward lower baseline D-Dimer levels (2.3 ± 2.5 vs. 19.8 ± 32.2 μg/mL, p = 0.056) compared to non-survivors. A logistic regression analysis suggested a borderline association between baseline D-Dimer levels and mortality with a 32% increase in the risk of death per 1 μg/mL increase (p = 0.055). CytoSorb was well-tolerated without any device-related adverse events reported.Conclusions: CytoSorb therapy for critically ill COVID-19 patients on ECMO was associated with high survival rates suggesting potential therapeutic benefit. Elevated baseline D-Dimer levels may suggest increased risk of mortality. Prospective controlled studies are warranted to substantiate these results.Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT0439192, identifier: NCT04391920.