Pub Date : 2024-07-22eCollection Date: 2024-07-01DOI: 10.1097/CCE.0000000000001117
Enzo Lüsebrink, Hugo Lanz, Leonhard Binzenhöfer, Sabine Hoffmann, Julia Höpler, Marie Kraft, Nils Gade, Jonas Gmeiner, Daniel Roden, Inas Saleh, Christian Hagl, Georg Nickenig, Steffen Massberg, Sebastian Zimmer, Raúl Nicolás Jamin, Clemens Scherer
Objectives: Cardiogenic shock (CS) is associated with high mortality. Patients treated for CS mostly require heparin therapy, which may be associated with complications such as heparin-induced thrombocytopenia (HIT). HIT represents a serious condition associated with platelet decline and increased hypercoagulability and remains a poorly researched field in intensive care medicine. Primary purpose of this study was to: 1) determine HIT prevalence in CS, 2) assess the performance of common diagnostic tests for the workup of HIT, and 3) compare outcomes in CS patients with excluded and confirmed HIT.
Design: Retrospective dual-center study including adult patients 18 years old or older with diagnosed CS and suspected HIT from January 2010 to November 2022.
Setting: Cardiac ICU at the Ludwig-Maximilians University hospital in Munich and the university hospital of Bonn.
Patients and interventions: In this retrospective analysis, adult patients with diagnosed CS and suspected HIT were included. Differences in baseline characteristics, mortality, neurologic and safety outcomes between patients with excluded and confirmed HIT were evaluated.
Measurements and main results: In cases of suspected HIT, positive screening antibodies were detected in 159 of 2808 patients (5.7%). HIT was confirmed via positive functional assay in 57 of 2808 patients, corresponding to a prevalence rate of 2.0%. The positive predictive value for anti-platelet factor 4/heparin screening antibodies was 35.8%. Total in-hospital mortality (58.8% vs. 57.9%; p > 0.999), 1-month mortality (47.1% vs. 43.9%; p = 0.781), and 12-month mortality (58.8% vs. 59.6%; p > 0.999) were similar between patients with excluded and confirmed HIT, respectively. Furthermore, no significant difference in neurologic outcome among survivors was found between groups (Cerebral Performance Category [CPC] score 1: 8.8% vs. 8.8%; p > 0.999 and CPC 2: 7.8% vs. 12.3%; p = 0.485).
Conclusions: HIT was a rare complication in CS patients treated with unfractionated heparin and was not associated with increased mortality. Also, HIT confirmation was not associated with worse neurologic outcome in survivors. Future studies should aim at developing more precise, standardized, and cost-effective strategies to diagnose HIT and prevent complications.
目的:心源性休克(CS)死亡率很高。治疗心源性休克的患者大多需要肝素治疗,而肝素治疗可能会引起肝素诱导血小板减少症(HIT)等并发症。HIT 是一种与血小板减少和高凝状态增加有关的严重病症,在重症监护医学领域仍是一个研究较少的领域。本研究的主要目的是1)确定 HIT 在重症监护中的发病率;2)评估用于 HIT 检查的常用诊断测试的性能;3)比较排除和确诊 HIT 的重症监护患者的预后:设计:回顾性双中心研究,包括2010年1月至2022年11月期间确诊为CS和疑似HIT的18岁或18岁以上成年患者:慕尼黑路德维希-马克西米利安大学医院和波恩大学医院心脏重症监护室:在这项回顾性分析中,纳入了确诊为CS和疑似HIT的成年患者。评估了排除 HIT 和确诊 HIT 患者在基线特征、死亡率、神经系统和安全结果方面的差异:在疑似 HIT 患者中,2808 例患者中有 159 例(5.7%)检测到阳性筛查抗体。在 2808 例患者中,有 57 例通过阳性功能测试确诊为 HIT,患病率为 2.0%。抗血小板因子 4/肝素筛查抗体的阳性预测值为 35.8%。排除型和确诊型 HIT 患者的院内总死亡率(58.8% 对 57.9%;P > 0.999)、1 个月死亡率(47.1% 对 43.9%;P = 0.781)和 12 个月死亡率(58.8% 对 59.6%;P > 0.999)分别相似。此外,各组幸存者的神经系统预后无明显差异(脑功能分类 [CPC] 评分 1:8.8% 对 8.8%;P > 0.999;CPC 评分 2:7.8% 对 12.3%;P = 0.485):HIT是接受非分叶肝素治疗的CS患者中罕见的并发症,与死亡率的增加无关。此外,HIT的确认与幸存者神经系统预后的恶化无关。未来的研究应致力于开发更精确、更标准化、更具成本效益的策略来诊断 HIT 并预防并发症。
{"title":"Heparin-Induced Thrombocytopenia in Patients Suffering Cardiogenic Shock.","authors":"Enzo Lüsebrink, Hugo Lanz, Leonhard Binzenhöfer, Sabine Hoffmann, Julia Höpler, Marie Kraft, Nils Gade, Jonas Gmeiner, Daniel Roden, Inas Saleh, Christian Hagl, Georg Nickenig, Steffen Massberg, Sebastian Zimmer, Raúl Nicolás Jamin, Clemens Scherer","doi":"10.1097/CCE.0000000000001117","DOIUrl":"10.1097/CCE.0000000000001117","url":null,"abstract":"<p><strong>Objectives: </strong>Cardiogenic shock (CS) is associated with high mortality. Patients treated for CS mostly require heparin therapy, which may be associated with complications such as heparin-induced thrombocytopenia (HIT). HIT represents a serious condition associated with platelet decline and increased hypercoagulability and remains a poorly researched field in intensive care medicine. Primary purpose of this study was to: 1) determine HIT prevalence in CS, 2) assess the performance of common diagnostic tests for the workup of HIT, and 3) compare outcomes in CS patients with excluded and confirmed HIT.</p><p><strong>Design: </strong>Retrospective dual-center study including adult patients 18 years old or older with diagnosed CS and suspected HIT from January 2010 to November 2022.</p><p><strong>Setting: </strong>Cardiac ICU at the Ludwig-Maximilians University hospital in Munich and the university hospital of Bonn.</p><p><strong>Patients and interventions: </strong>In this retrospective analysis, adult patients with diagnosed CS and suspected HIT were included. Differences in baseline characteristics, mortality, neurologic and safety outcomes between patients with excluded and confirmed HIT were evaluated.</p><p><strong>Measurements and main results: </strong>In cases of suspected HIT, positive screening antibodies were detected in 159 of 2808 patients (5.7%). HIT was confirmed via positive functional assay in 57 of 2808 patients, corresponding to a prevalence rate of 2.0%. The positive predictive value for anti-platelet factor 4/heparin screening antibodies was 35.8%. Total in-hospital mortality (58.8% vs. 57.9%; p > 0.999), 1-month mortality (47.1% vs. 43.9%; p = 0.781), and 12-month mortality (58.8% vs. 59.6%; p > 0.999) were similar between patients with excluded and confirmed HIT, respectively. Furthermore, no significant difference in neurologic outcome among survivors was found between groups (Cerebral Performance Category [CPC] score 1: 8.8% vs. 8.8%; p > 0.999 and CPC 2: 7.8% vs. 12.3%; p = 0.485).</p><p><strong>Conclusions: </strong>HIT was a rare complication in CS patients treated with unfractionated heparin and was not associated with increased mortality. Also, HIT confirmation was not associated with worse neurologic outcome in survivors. Future studies should aim at developing more precise, standardized, and cost-effective strategies to diagnose HIT and prevent complications.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11265775/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141753592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-22eCollection Date: 2024-07-01DOI: 10.1097/CCE.0000000000001117
Enzo Lüsebrink, Hugo Lanz, Leonhard Binzenhöfer, Sabine Hoffmann, Julia Höpler, Marie Kraft, Nils Gade, Jonas Gmeiner, Daniel Roden, Inas Saleh, Christian Hagl, Georg Nickenig, Steffen Massberg, Sebastian Zimmer, Raúl Nicolás Jamin, Clemens Scherer
Objectives: Cardiogenic shock (CS) is associated with high mortality. Patients treated for CS mostly require heparin therapy, which may be associated with complications such as heparin-induced thrombocytopenia (HIT). HIT represents a serious condition associated with platelet decline and increased hypercoagulability and remains a poorly researched field in intensive care medicine. Primary purpose of this study was to: 1) determine HIT prevalence in CS, 2) assess the performance of common diagnostic tests for the workup of HIT, and 3) compare outcomes in CS patients with excluded and confirmed HIT.
Design: Retrospective dual-center study including adult patients 18 years old or older with diagnosed CS and suspected HIT from January 2010 to November 2022.
Setting: Cardiac ICU at the Ludwig-Maximilians University hospital in Munich and the university hospital of Bonn.
Patients and interventions: In this retrospective analysis, adult patients with diagnosed CS and suspected HIT were included. Differences in baseline characteristics, mortality, neurologic and safety outcomes between patients with excluded and confirmed HIT were evaluated.
Measurements and main results: In cases of suspected HIT, positive screening antibodies were detected in 159 of 2808 patients (5.7%). HIT was confirmed via positive functional assay in 57 of 2808 patients, corresponding to a prevalence rate of 2.0%. The positive predictive value for anti-platelet factor 4/heparin screening antibodies was 35.8%. Total in-hospital mortality (58.8% vs. 57.9%; p > 0.999), 1-month mortality (47.1% vs. 43.9%; p = 0.781), and 12-month mortality (58.8% vs. 59.6%; p > 0.999) were similar between patients with excluded and confirmed HIT, respectively. Furthermore, no significant difference in neurologic outcome among survivors was found between groups (Cerebral Performance Category [CPC] score 1: 8.8% vs. 8.8%; p > 0.999 and CPC 2: 7.8% vs. 12.3%; p = 0.485).
Conclusions: HIT was a rare complication in CS patients treated with unfractionated heparin and was not associated with increased mortality. Also, HIT confirmation was not associated with worse neurologic outcome in survivors. Future studies should aim at developing more precise, standardized, and cost-effective strategies to diagnose HIT and prevent complications.
目的:心源性休克(CS)死亡率很高。治疗心源性休克的患者大多需要肝素治疗,而肝素治疗可能会引起肝素诱导血小板减少症(HIT)等并发症。HIT 是一种与血小板减少和高凝状态增加有关的严重病症,在重症监护医学领域仍是一个研究较少的领域。本研究的主要目的是1)确定 HIT 在重症监护中的发病率;2)评估用于 HIT 检查的常用诊断测试的性能;3)比较排除和确诊 HIT 的重症监护患者的预后:设计:回顾性双中心研究,包括2010年1月至2022年11月期间确诊为CS和疑似HIT的18岁或18岁以上成年患者:慕尼黑路德维希-马克西米利安大学医院和波恩大学医院心脏重症监护室:在这项回顾性分析中,纳入了确诊为CS和疑似HIT的成年患者。评估了排除 HIT 和确诊 HIT 患者在基线特征、死亡率、神经系统和安全结果方面的差异:在疑似 HIT 的病例中,2808 例患者中有 159 例(5.7%)检测到阳性筛查抗体。在 2808 例患者中,有 57 例通过阳性功能测试确诊为 HIT,患病率为 2.0%。抗血小板因子 4/肝素筛查抗体的阳性预测值为 35.8%。排除型和确诊型 HIT 患者的院内总死亡率(58.8% 对 57.9%;P > 0.999)、1 个月死亡率(47.1% 对 43.9%;P = 0.781)和 12 个月死亡率(58.8% 对 59.6%;P > 0.999)分别相似。此外,各组幸存者的神经系统预后无明显差异(脑功能分类 [CPC] 评分 1:8.8% 对 8.8%;P > 0.999;CPC 评分 2:7.8% 对 12.3%;P = 0.485):HIT是接受非分叶肝素治疗的CS患者中罕见的并发症,与死亡率的增加无关。此外,HIT的确认与幸存者神经系统预后的恶化无关。未来的研究应致力于开发更精确、更标准化、更具成本效益的策略来诊断 HIT 并预防并发症。
{"title":"Heparin-Induced Thrombocytopenia in Patients Suffering Cardiogenic Shock.","authors":"Enzo Lüsebrink, Hugo Lanz, Leonhard Binzenhöfer, Sabine Hoffmann, Julia Höpler, Marie Kraft, Nils Gade, Jonas Gmeiner, Daniel Roden, Inas Saleh, Christian Hagl, Georg Nickenig, Steffen Massberg, Sebastian Zimmer, Raúl Nicolás Jamin, Clemens Scherer","doi":"10.1097/CCE.0000000000001117","DOIUrl":"10.1097/CCE.0000000000001117","url":null,"abstract":"<p><strong>Objectives: </strong>Cardiogenic shock (CS) is associated with high mortality. Patients treated for CS mostly require heparin therapy, which may be associated with complications such as heparin-induced thrombocytopenia (HIT). HIT represents a serious condition associated with platelet decline and increased hypercoagulability and remains a poorly researched field in intensive care medicine. Primary purpose of this study was to: 1) determine HIT prevalence in CS, 2) assess the performance of common diagnostic tests for the workup of HIT, and 3) compare outcomes in CS patients with excluded and confirmed HIT.</p><p><strong>Design: </strong>Retrospective dual-center study including adult patients 18 years old or older with diagnosed CS and suspected HIT from January 2010 to November 2022.</p><p><strong>Setting: </strong>Cardiac ICU at the Ludwig-Maximilians University hospital in Munich and the university hospital of Bonn.</p><p><strong>Patients and interventions: </strong>In this retrospective analysis, adult patients with diagnosed CS and suspected HIT were included. Differences in baseline characteristics, mortality, neurologic and safety outcomes between patients with excluded and confirmed HIT were evaluated.</p><p><strong>Measurements and main results: </strong>In cases of suspected HIT, positive screening antibodies were detected in 159 of 2808 patients (5.7%). HIT was confirmed via positive functional assay in 57 of 2808 patients, corresponding to a prevalence rate of 2.0%. The positive predictive value for anti-platelet factor 4/heparin screening antibodies was 35.8%. Total in-hospital mortality (58.8% vs. 57.9%; <i>p</i> > 0.999), 1-month mortality (47.1% vs. 43.9%; <i>p</i> = 0.781), and 12-month mortality (58.8% vs. 59.6%; <i>p</i> > 0.999) were similar between patients with excluded and confirmed HIT, respectively. Furthermore, no significant difference in neurologic outcome among survivors was found between groups (Cerebral Performance Category [CPC] score 1: 8.8% vs. 8.8%; <i>p</i> > 0.999 and CPC 2: 7.8% vs. 12.3%; <i>p</i> = 0.485).</p><p><strong>Conclusions: </strong>HIT was a rare complication in CS patients treated with unfractionated heparin and was not associated with increased mortality. Also, HIT confirmation was not associated with worse neurologic outcome in survivors. Future studies should aim at developing more precise, standardized, and cost-effective strategies to diagnose HIT and prevent complications.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11265775/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141753591","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-19eCollection Date: 2024-07-01DOI: 10.1097/CCE.0000000000001116
Sushant Govindan, Alexandra Spicer, Matthew Bearce, Richard S Schaefer, Andrea Uhl, Gil Alterovitz, Michael J Kim, Kyle A Carey, Nirav S Shah, Christopher Winslow, Emily Gilbert, Anne Stey, Alan M Weiss, Devendra Amin, George Karway, Jennie Martin, Dana P Edelson, Matthew M Churpek
Background and objective: To develop the COVid Veteran (COVet) score for clinical deterioration in Veterans hospitalized with COVID-19 and further validate this model in both Veteran and non-Veteran samples. No such score has been derived and validated while incorporating a Veteran sample.
Derivation cohort: Adults (age ≥ 18 yr) hospitalized outside the ICU with a diagnosis of COVID-19 for model development to the Veterans Health Administration (VHA) (n = 80 hospitals).
Validation cohort: External validation occurred in a VHA cohort of 34 hospitals, as well as six non-Veteran health systems for further external validation (n = 21 hospitals) between 2020 and 2023.
Prediction model: eXtreme Gradient Boosting machine learning methods were used, and performance was assessed using the area under the receiver operating characteristic curve and compared with the National Early Warning Score (NEWS). The primary outcome was transfer to the ICU or death within 24 hours of each new variable observation. Model predictor variables included demographics, vital signs, structured flowsheet data, and laboratory values.
Results: A total of 96,908 admissions occurred during the study period, of which 59,897 were in the Veteran sample and 37,011 were in the non-Veteran sample. During external validation in the Veteran sample, the model demonstrated excellent discrimination, with an area under the receiver operating characteristic curve of 0.88. This was significantly higher than NEWS (0.79; p < 0.01). In the non-Veteran sample, the model also demonstrated excellent discrimination (0.86 vs. 0.79 for NEWS; p < 0.01). The top three variables of importance were eosinophil percentage, mean oxygen saturation in the prior 24-hour period, and worst mental status in the prior 24-hour period.
Conclusions: We used machine learning methods to develop and validate a highly accurate early warning score in both Veterans and non-Veterans hospitalized with COVID-19. The model could lead to earlier identification and therapy, which may improve outcomes.
{"title":"Development and Validation of a Machine Learning COVID-19 Veteran (COVet) Deterioration Risk Score.","authors":"Sushant Govindan, Alexandra Spicer, Matthew Bearce, Richard S Schaefer, Andrea Uhl, Gil Alterovitz, Michael J Kim, Kyle A Carey, Nirav S Shah, Christopher Winslow, Emily Gilbert, Anne Stey, Alan M Weiss, Devendra Amin, George Karway, Jennie Martin, Dana P Edelson, Matthew M Churpek","doi":"10.1097/CCE.0000000000001116","DOIUrl":"10.1097/CCE.0000000000001116","url":null,"abstract":"<p><strong>Background and objective: </strong>To develop the COVid Veteran (COVet) score for clinical deterioration in Veterans hospitalized with COVID-19 and further validate this model in both Veteran and non-Veteran samples. No such score has been derived and validated while incorporating a Veteran sample.</p><p><strong>Derivation cohort: </strong>Adults (age ≥ 18 yr) hospitalized outside the ICU with a diagnosis of COVID-19 for model development to the Veterans Health Administration (VHA) (n = 80 hospitals).</p><p><strong>Validation cohort: </strong>External validation occurred in a VHA cohort of 34 hospitals, as well as six non-Veteran health systems for further external validation (n = 21 hospitals) between 2020 and 2023.</p><p><strong>Prediction model: </strong>eXtreme Gradient Boosting machine learning methods were used, and performance was assessed using the area under the receiver operating characteristic curve and compared with the National Early Warning Score (NEWS). The primary outcome was transfer to the ICU or death within 24 hours of each new variable observation. Model predictor variables included demographics, vital signs, structured flowsheet data, and laboratory values.</p><p><strong>Results: </strong>A total of 96,908 admissions occurred during the study period, of which 59,897 were in the Veteran sample and 37,011 were in the non-Veteran sample. During external validation in the Veteran sample, the model demonstrated excellent discrimination, with an area under the receiver operating characteristic curve of 0.88. This was significantly higher than NEWS (0.79; p < 0.01). In the non-Veteran sample, the model also demonstrated excellent discrimination (0.86 vs. 0.79 for NEWS; p < 0.01). The top three variables of importance were eosinophil percentage, mean oxygen saturation in the prior 24-hour period, and worst mental status in the prior 24-hour period.</p><p><strong>Conclusions: </strong>We used machine learning methods to develop and validate a highly accurate early warning score in both Veterans and non-Veterans hospitalized with COVID-19. The model could lead to earlier identification and therapy, which may improve outcomes.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11262818/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141728468","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-18eCollection Date: 2024-07-01DOI: 10.1097/CCE.0000000000001122
Vikramjit Mukherjee, Radu Postelnicu, Chelsie Parker, Patrick S Rivers, George L Anesi, Adair Andrews, Erin Ables, Eric D Morrell, David M Brett-Major, M Jana Broadhurst, J Perren Cobb, Amy Irwin, Christopher J Kratochvil, Kelsey Krolikowski, Vishakha K Kumar, Douglas P Landsittel, Richard A Lee, Janice M Liebler, Leopoldo N Segal, Jonathan E Sevransky, Avantika Srivastava, Timothy M Uyeki, Mark M Wurfel, David Wyles, Laura E Evans, Karen Lutrick, Pavan K Bhatraju
Importance: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has evolved through multiple phases in the United States, with significant differences in patient centered outcomes with improvements in hospital strain, medical countermeasures, and overall understanding of the disease. We describe how patient characteristics changed and care progressed over the various pandemic phases; we also emphasize the need for an ongoing clinical network to improve the understanding of known and novel respiratory viral diseases.
Objectives: To describe how patient characteristics and care evolved across the various COVID-19 pandemic periods in those hospitalized with viral severe acute respiratory infection (SARI).
Design: Severe Acute Respiratory Infection-Preparedness (SARI-PREP) is a Centers for Disease Control and Prevention Foundation-funded, Society of Critical Care Medicine Discovery-housed, longitudinal multicenter cohort study of viral pneumonia. We defined SARI patients as those hospitalized with laboratory-confirmed respiratory viral infection and an acute syndrome of fever, cough, and radiographic infiltrates or hypoxemia. We collected patient-level data including demographic characteristics, comorbidities, acute physiologic measures, serum and respiratory specimens, therapeutics, and outcomes. Outcomes were described across four pandemic variant periods based on a SARS-CoV-2 sequenced subsample: pre-Delta, Delta, Omicron BA.1, and Omicron post-BA.1.
Setting: Multicenter cohort of adult patients admitted to an acute care ward or ICU from seven hospitals representing diverse geographic regions across the United States.
Participants: Patients with SARI caused by infection with respiratory viruses.
Main outcomes and results: Eight hundred seventy-four adult patients with SARI were enrolled at seven study hospitals between March 2020 and April 2023. Most patients (780, 89%) had SARS-CoV-2 infection. Across the COVID-19 cohort, median age was 60 years (interquartile range, 48.0-71.0 yr) and 66% were male. Almost half (430, 49%) of the study population belonged to underserved communities. Most patients (76.5%) were admitted to the ICU, 52.5% received mechanical ventilation, and observed hospital mortality was 25.5%. As the pandemic progressed, we observed decreases in ICU utilization (94% to 58%), hospital length of stay (median, 26.0 to 8.5 d), and hospital mortality (32% to 12%), while the number of comorbid conditions increased.
Conclusions and relevance: We describe increasing comorbidities but improved outcomes across pandemic variant periods, in the setting of multiple factors, including evolving care delivery, countermeasures, and viral variants. An understanding of patient-level factors may inform treatment options for subsequent variants and future novel pathogens.
{"title":"COVID-19 Across Pandemic Variant Periods: The Severe Acute Respiratory Infection-Preparedness (SARI-PREP) Study.","authors":"Vikramjit Mukherjee, Radu Postelnicu, Chelsie Parker, Patrick S Rivers, George L Anesi, Adair Andrews, Erin Ables, Eric D Morrell, David M Brett-Major, M Jana Broadhurst, J Perren Cobb, Amy Irwin, Christopher J Kratochvil, Kelsey Krolikowski, Vishakha K Kumar, Douglas P Landsittel, Richard A Lee, Janice M Liebler, Leopoldo N Segal, Jonathan E Sevransky, Avantika Srivastava, Timothy M Uyeki, Mark M Wurfel, David Wyles, Laura E Evans, Karen Lutrick, Pavan K Bhatraju","doi":"10.1097/CCE.0000000000001122","DOIUrl":"10.1097/CCE.0000000000001122","url":null,"abstract":"<p><strong>Importance: </strong>The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has evolved through multiple phases in the United States, with significant differences in patient centered outcomes with improvements in hospital strain, medical countermeasures, and overall understanding of the disease. We describe how patient characteristics changed and care progressed over the various pandemic phases; we also emphasize the need for an ongoing clinical network to improve the understanding of known and novel respiratory viral diseases.</p><p><strong>Objectives: </strong>To describe how patient characteristics and care evolved across the various COVID-19 pandemic periods in those hospitalized with viral severe acute respiratory infection (SARI).</p><p><strong>Design: </strong>Severe Acute Respiratory Infection-Preparedness (SARI-PREP) is a Centers for Disease Control and Prevention Foundation-funded, Society of Critical Care Medicine Discovery-housed, longitudinal multicenter cohort study of viral pneumonia. We defined SARI patients as those hospitalized with laboratory-confirmed respiratory viral infection and an acute syndrome of fever, cough, and radiographic infiltrates or hypoxemia. We collected patient-level data including demographic characteristics, comorbidities, acute physiologic measures, serum and respiratory specimens, therapeutics, and outcomes. Outcomes were described across four pandemic variant periods based on a SARS-CoV-2 sequenced subsample: pre-Delta, Delta, Omicron BA.1, and Omicron post-BA.1.</p><p><strong>Setting: </strong>Multicenter cohort of adult patients admitted to an acute care ward or ICU from seven hospitals representing diverse geographic regions across the United States.</p><p><strong>Participants: </strong>Patients with SARI caused by infection with respiratory viruses.</p><p><strong>Main outcomes and results: </strong>Eight hundred seventy-four adult patients with SARI were enrolled at seven study hospitals between March 2020 and April 2023. Most patients (780, 89%) had SARS-CoV-2 infection. Across the COVID-19 cohort, median age was 60 years (interquartile range, 48.0-71.0 yr) and 66% were male. Almost half (430, 49%) of the study population belonged to underserved communities. Most patients (76.5%) were admitted to the ICU, 52.5% received mechanical ventilation, and observed hospital mortality was 25.5%. As the pandemic progressed, we observed decreases in ICU utilization (94% to 58%), hospital length of stay (median, 26.0 to 8.5 d), and hospital mortality (32% to 12%), while the number of comorbid conditions increased.</p><p><strong>Conclusions and relevance: </strong>We describe increasing comorbidities but improved outcomes across pandemic variant periods, in the setting of multiple factors, including evolving care delivery, countermeasures, and viral variants. An understanding of patient-level factors may inform treatment options for subsequent variants and future novel pathogens.</p","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11259394/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141636149","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-17eCollection Date: 2024-07-01DOI: 10.1097/CCE.0000000000001127
Chad H Hochberg, Aaron S Case, Kevin J Psoter, Daniel Brodie, Rebecca H Dezube, Sarina K Sahetya, Carrie Outten, Lara Street, Michelle N Eakin, David N Hager
Objective: During the COVID-19 pandemic, some centers converted intermediate care units (IMCUs) to COVID-19 ICUs (IMCU/ICUs). In this study, we compared adherence to lung protective ventilation (LPV) and outcomes for patients with COVID-19-related acute respiratory distress syndrome (ARDS) treated in an IMCU/ICU versus preexisting medical ICUs (MICUs).
Design: Retrospective observational study using electronic medical record data.
Setting: Two academic medical centers from March 2020 to September 2020 (period 1) and October 2020 to May 2021 (period 2), which capture the first two COVID-19 surges in this health system.
Patients: Adults with COVID-19 receiving invasive mechanical ventilation who met ARDS oxygenation criteria (Pao2/Fio2 ≤ 300 mm Hg or Spo2/Fio2 ≤ 315).
Interventions: None.
Measurements and main results: We defined LPV adherence as the percent of the first 48 hours of mechanical ventilation that met a restrictive definition of LPV of, tidal volume/predicted body weight (Vt/PBW) less than or equal to 6.5 mL/kg and plateau pressure (Pplat) less than or equal to 30 cm H2o. In an expanded definition, we added that if Pplat is greater than 30 cm H2o, Vt/PBW had to be less than 6.0 mL/kg. Using the restricted definition, period 1 adherence was lower among 133 IMCU/ICU versus 199 MICU patients (92% [95% CI, 50-100] vs. 100% [86-100], p = 0.05). Period 2 adherence was similar between groups (100% [75-100] vs. 95% CI [65-100], p = 0.68). A similar pattern was observed using the expanded definition. For the full study period, the adjusted hazard of death at 90 days was lower in IMCU/ICU versus MICU patients (hazard ratio [HR] 0.73 [95% CI, 0.55-0.99]), whereas ventilator liberation by day 28 was similar between groups (adjusted subdistribution HR 1.09 [95% CI, 0.85-1.39]).
Conclusions: In patients with COVID-19 ARDS treated in an IMCU/ICU, LPV adherence was similar to, and observed survival better than those treated in preexisting MICUs. With adequate resources, protocols, and staffing, IMCUs provide an effective source of additional ICU capacity for patients with acute respiratory failure.
{"title":"Lung Protective Ventilation Adherence and Outcomes for Patients With COVID-19 Acute Respiratory Distress Syndrome Treated in an Intermediate Care Unit Repurposed to ICU Level of Care.","authors":"Chad H Hochberg, Aaron S Case, Kevin J Psoter, Daniel Brodie, Rebecca H Dezube, Sarina K Sahetya, Carrie Outten, Lara Street, Michelle N Eakin, David N Hager","doi":"10.1097/CCE.0000000000001127","DOIUrl":"10.1097/CCE.0000000000001127","url":null,"abstract":"<p><strong>Objective: </strong>During the COVID-19 pandemic, some centers converted intermediate care units (IMCUs) to COVID-19 ICUs (IMCU/ICUs). In this study, we compared adherence to lung protective ventilation (LPV) and outcomes for patients with COVID-19-related acute respiratory distress syndrome (ARDS) treated in an IMCU/ICU versus preexisting medical ICUs (MICUs).</p><p><strong>Design: </strong>Retrospective observational study using electronic medical record data.</p><p><strong>Setting: </strong>Two academic medical centers from March 2020 to September 2020 (period 1) and October 2020 to May 2021 (period 2), which capture the first two COVID-19 surges in this health system.</p><p><strong>Patients: </strong>Adults with COVID-19 receiving invasive mechanical ventilation who met ARDS oxygenation criteria (Pao2/Fio2 ≤ 300 mm Hg or Spo2/Fio2 ≤ 315).</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We defined LPV adherence as the percent of the first 48 hours of mechanical ventilation that met a restrictive definition of LPV of, tidal volume/predicted body weight (Vt/PBW) less than or equal to 6.5 mL/kg and plateau pressure (Pplat) less than or equal to 30 cm H2o. In an expanded definition, we added that if Pplat is greater than 30 cm H2o, Vt/PBW had to be less than 6.0 mL/kg. Using the restricted definition, period 1 adherence was lower among 133 IMCU/ICU versus 199 MICU patients (92% [95% CI, 50-100] vs. 100% [86-100], p = 0.05). Period 2 adherence was similar between groups (100% [75-100] vs. 95% CI [65-100], p = 0.68). A similar pattern was observed using the expanded definition. For the full study period, the adjusted hazard of death at 90 days was lower in IMCU/ICU versus MICU patients (hazard ratio [HR] 0.73 [95% CI, 0.55-0.99]), whereas ventilator liberation by day 28 was similar between groups (adjusted subdistribution HR 1.09 [95% CI, 0.85-1.39]).</p><p><strong>Conclusions: </strong>In patients with COVID-19 ARDS treated in an IMCU/ICU, LPV adherence was similar to, and observed survival better than those treated in preexisting MICUs. With adequate resources, protocols, and staffing, IMCUs provide an effective source of additional ICU capacity for patients with acute respiratory failure.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11257666/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141636150","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-17eCollection Date: 2024-07-01DOI: 10.1097/CCE.0000000000001123
Laura C Myers, Nicholas A Bosch, Lauren Soltesz, Kathleen A Daly, Cynthia I Campbell, Emma Schwager, Emmanuele Salvati, Jennifer P Stevens, Hannah Wunsch, Justin M Rucci, S Reza Jafarzadeh, Vincent X Liu, Allan J Walkey
Importance: The opioid crisis is impacting people across the country and deserves attention to be able to curb the rise in opioid-related deaths.
Objectives: To evaluate practice patterns in opioid infusion administration and dosing for patients with acute respiratory failure receiving invasive mechanical ventilation.
Design: Retrospective cohort study.
Setting and participants: Patients from 21 hospitals in Kaiser Permanente Northern California and 96 hospitals in Philips electronic ICU Research Institute.
Main outcomes and measures: We assessed whether patients received opioid infusion and the dose of said opioid infusion.
Results: We identified patients with a diagnosis of acute respiratory failure who were initiated on invasive mechanical ventilation. From each patient, we determined if opioid infusions were administered and, among those who received an opioid infusion, the median daily dose of fentanyl infusion. We used hierarchical regression models to quantify variation in opioid infusion use and the median daily dose of fentanyl equivalents across hospitals. We included 13,140 patients in the KPNC cohort and 52,033 patients in the eRI cohort. A total of 7,023 (53.4%) and 16,311 (31.1%) patients received an opioid infusion in the first 21 days of mechanical ventilation in the KPNC and eRI cohorts, respectively. After accounting for patient- and hospital-level fixed effects, the hospital that a patient was admitted to explained 7% (95% CI, 3-11%) and 39% (95% CI, 28-49%) of the variation in opioid infusion use in the KPNC and eRI cohorts, respectively. Among patients who received an opioid infusion, the median daily fentanyl equivalent dose was 692 µg (interquartile range [IQR], 129-1341 µg) in the KPNC cohort and 200 µg (IQR, 0-1050 µg) in the eRI cohort. Hospital explained 4% (95% CI, 1-7%) and 20% (95% CI, 15-26%) of the variation in median daily fentanyl equivalent dose in the KPNC and eRI cohorts, respectively.
Conclusions and relevance: In the context of efforts to limit healthcare-associated opioid exposure, our findings highlight the considerable opioid exposure that accompanies mechanical ventilation and suggest potential under and over-treatment with analgesia. Our results facilitate benchmarking of hospitals' analgesia practices against risk-adjusted averages and can be used to inform usual care control arms of analgesia and sedation clinical trials.
{"title":"Opioid Administration Practice Patterns in Patients With Acute Respiratory Failure Who Undergo Invasive Mechanical Ventilation.","authors":"Laura C Myers, Nicholas A Bosch, Lauren Soltesz, Kathleen A Daly, Cynthia I Campbell, Emma Schwager, Emmanuele Salvati, Jennifer P Stevens, Hannah Wunsch, Justin M Rucci, S Reza Jafarzadeh, Vincent X Liu, Allan J Walkey","doi":"10.1097/CCE.0000000000001123","DOIUrl":"10.1097/CCE.0000000000001123","url":null,"abstract":"<p><strong>Importance: </strong>The opioid crisis is impacting people across the country and deserves attention to be able to curb the rise in opioid-related deaths.</p><p><strong>Objectives: </strong>To evaluate practice patterns in opioid infusion administration and dosing for patients with acute respiratory failure receiving invasive mechanical ventilation.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting and participants: </strong>Patients from 21 hospitals in Kaiser Permanente Northern California and 96 hospitals in Philips electronic ICU Research Institute.</p><p><strong>Main outcomes and measures: </strong>We assessed whether patients received opioid infusion and the dose of said opioid infusion.</p><p><strong>Results: </strong>We identified patients with a diagnosis of acute respiratory failure who were initiated on invasive mechanical ventilation. From each patient, we determined if opioid infusions were administered and, among those who received an opioid infusion, the median daily dose of fentanyl infusion. We used hierarchical regression models to quantify variation in opioid infusion use and the median daily dose of fentanyl equivalents across hospitals. We included 13,140 patients in the KPNC cohort and 52,033 patients in the eRI cohort. A total of 7,023 (53.4%) and 16,311 (31.1%) patients received an opioid infusion in the first 21 days of mechanical ventilation in the KPNC and eRI cohorts, respectively. After accounting for patient- and hospital-level fixed effects, the hospital that a patient was admitted to explained 7% (95% CI, 3-11%) and 39% (95% CI, 28-49%) of the variation in opioid infusion use in the KPNC and eRI cohorts, respectively. Among patients who received an opioid infusion, the median daily fentanyl equivalent dose was 692 µg (interquartile range [IQR], 129-1341 µg) in the KPNC cohort and 200 µg (IQR, 0-1050 µg) in the eRI cohort. Hospital explained 4% (95% CI, 1-7%) and 20% (95% CI, 15-26%) of the variation in median daily fentanyl equivalent dose in the KPNC and eRI cohorts, respectively.</p><p><strong>Conclusions and relevance: </strong>In the context of efforts to limit healthcare-associated opioid exposure, our findings highlight the considerable opioid exposure that accompanies mechanical ventilation and suggest potential under and over-treatment with analgesia. Our results facilitate benchmarking of hospitals' analgesia practices against risk-adjusted averages and can be used to inform usual care control arms of analgesia and sedation clinical trials.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11257673/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141636109","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-16eCollection Date: 2024-07-01DOI: 10.1097/CCE.0000000000001118
Sophie E Ack, Rianne G F Dolmans, Brandon Foreman, Geoffrey T Manley, Eric S Rosenthal, Morteza Zabihi
Importance: Treatment for intracranial pressure (ICP) has been increasingly informed by machine learning (ML)-derived ICP waveform characteristics. There are gaps, however, in understanding how ICP monitor type may bias waveform characteristics used for these predictive tools since differences between external ventricular drain (EVD) and intraparenchymal monitor (IPM)-derived waveforms have not been well accounted for.
Objectives: We sought to develop a proof-of-concept ML model differentiating ICP waveforms originating from an EVD or IPM.
Design, setting, and participants: We examined raw ICP waveform data from the ICU physiology cohort within the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury multicenter study.
Main outcomes and measures: Nested patient-wise five-fold cross-validation and group analysis with bagged decision trees (BDT) and linear discriminant analysis were used for feature selection and fair evaluation. Nine patients were kept as unseen hold-outs for further evaluation.
Results: ICP waveform data totaling 14,110 hours were included from 82 patients (EVD, 47; IPM, 26; both, 9). Mean age, Glasgow Coma Scale (GCS) total, and GCS motor score upon admission, as well as the presence and amount of midline shift, were similar between groups. The model mean area under the receiver operating characteristic curve (AU-ROC) exceeded 0.874 across all folds. In additional rigorous cluster-based subgroup analysis, targeted at testing the resilience of models to cross-validation with smaller subsets constructed to develop models in one confounder set and test them in another subset, AU-ROC exceeded 0.811. In a similar analysis using propensity score-based rather than cluster-based subgroup analysis, the mean AU-ROC exceeded 0.827. Of 842 extracted ICP features, 62 were invariant within every analysis, representing the most accurate and robust differences between ICP monitor types. For the nine patient hold-outs, an AU-ROC of 0.826 was obtained using BDT.
Conclusions and relevance: The developed proof-of-concept ML model identified differences in EVD- and IPM-derived ICP signals, which can provide missing contextual data for large-scale retrospective datasets, prevent bias in computational models that ingest ICP data indiscriminately, and control for confounding using our model's output as a propensity score by to adjust for the monitoring method that was clinically indicated. Furthermore, the invariant features may be leveraged as ICP features for anomaly detection.
{"title":"Deriving Automated Device Metadata From Intracranial Pressure Waveforms: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury ICU Physiology Cohort Analysis.","authors":"Sophie E Ack, Rianne G F Dolmans, Brandon Foreman, Geoffrey T Manley, Eric S Rosenthal, Morteza Zabihi","doi":"10.1097/CCE.0000000000001118","DOIUrl":"10.1097/CCE.0000000000001118","url":null,"abstract":"<p><strong>Importance: </strong>Treatment for intracranial pressure (ICP) has been increasingly informed by machine learning (ML)-derived ICP waveform characteristics. There are gaps, however, in understanding how ICP monitor type may bias waveform characteristics used for these predictive tools since differences between external ventricular drain (EVD) and intraparenchymal monitor (IPM)-derived waveforms have not been well accounted for.</p><p><strong>Objectives: </strong>We sought to develop a proof-of-concept ML model differentiating ICP waveforms originating from an EVD or IPM.</p><p><strong>Design, setting, and participants: </strong>We examined raw ICP waveform data from the ICU physiology cohort within the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury multicenter study.</p><p><strong>Main outcomes and measures: </strong>Nested patient-wise five-fold cross-validation and group analysis with bagged decision trees (BDT) and linear discriminant analysis were used for feature selection and fair evaluation. Nine patients were kept as unseen hold-outs for further evaluation.</p><p><strong>Results: </strong>ICP waveform data totaling 14,110 hours were included from 82 patients (EVD, 47; IPM, 26; both, 9). Mean age, Glasgow Coma Scale (GCS) total, and GCS motor score upon admission, as well as the presence and amount of midline shift, were similar between groups. The model mean area under the receiver operating characteristic curve (AU-ROC) exceeded 0.874 across all folds. In additional rigorous cluster-based subgroup analysis, targeted at testing the resilience of models to cross-validation with smaller subsets constructed to develop models in one confounder set and test them in another subset, AU-ROC exceeded 0.811. In a similar analysis using propensity score-based rather than cluster-based subgroup analysis, the mean AU-ROC exceeded 0.827. Of 842 extracted ICP features, 62 were invariant within every analysis, representing the most accurate and robust differences between ICP monitor types. For the nine patient hold-outs, an AU-ROC of 0.826 was obtained using BDT.</p><p><strong>Conclusions and relevance: </strong>The developed proof-of-concept ML model identified differences in EVD- and IPM-derived ICP signals, which can provide missing contextual data for large-scale retrospective datasets, prevent bias in computational models that ingest ICP data indiscriminately, and control for confounding using our model's output as a propensity score by to adjust for the monitoring method that was clinically indicated. Furthermore, the invariant features may be leveraged as ICP features for anomaly detection.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11254120/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141629583","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-16eCollection Date: 2024-07-01DOI: 10.1097/CCE.0000000000001128
Nikolai Ravn Aarskog, Ronja Hallem, Jakob Strand Godhavn, Morten Rostrup
Objectives background: Under normal conditions, pulmonary megakaryocytes are an important source of circulating thrombocytes, causing thrombocyte counts to be higher in arterial than venous blood. In critical COVID-19, thrombocytes may be removed from the circulation by the lungs because of immunothrombosis, possibly causing venous thrombocyte counts to be higher than arterial thrombocyte counts. In the present study, we investigated time-dependent changes in pulmonary turnover of thrombocytes during critical COVID-19 by measuring arteriovenous thrombocyte differences. We hypothesized that the early stages of the disease would be characterized by a net pulmonary removal of circulating thrombocytes because of immunothrombosis and that later stages would be characterized by a net pulmonary release of thrombocytes as normal pulmonary function is restored.
Design: Cohort study with repeated measurements of arterial and central venous thrombocyte counts.
Setting: ICU in a large university hospital.
Patients: Thirty-one patients with critical COVID-19 that were admitted to the ICU and received invasive or noninvasive mechanical ventilation.
Interventions: None.
Measurements and main results: We found a significant positive association between the arteriovenous thrombocyte difference and time since symptom debut. This finding indicates a negative arteriovenous thrombocyte difference and hence pulmonary removal of thrombocytes in the early stages of the disease and a positive arteriovenous thrombocyte difference and hence pulmonary release of thrombocytes in later stages. Most individual arteriovenous thrombocyte differences were smaller than the variance coefficient of the analysis.
Conclusions: The results of this study support our hypothesis that early stages of critical COVID-19 are characterized by pulmonary removal of circulating thrombocytes because of immunothrombosis and that later stages are characterized by the return of normal pulmonary release of thrombocytes. However, in most cases, the arteriovenous thrombocyte difference was too small to say anything about pulmonary thrombocyte removal and release on an individual level.
{"title":"Time-Dependent Changes in Pulmonary Turnover of Thrombocytes During Critical COVID-19.","authors":"Nikolai Ravn Aarskog, Ronja Hallem, Jakob Strand Godhavn, Morten Rostrup","doi":"10.1097/CCE.0000000000001128","DOIUrl":"10.1097/CCE.0000000000001128","url":null,"abstract":"<p><strong>Objectives background: </strong>Under normal conditions, pulmonary megakaryocytes are an important source of circulating thrombocytes, causing thrombocyte counts to be higher in arterial than venous blood. In critical COVID-19, thrombocytes may be removed from the circulation by the lungs because of immunothrombosis, possibly causing venous thrombocyte counts to be higher than arterial thrombocyte counts. In the present study, we investigated time-dependent changes in pulmonary turnover of thrombocytes during critical COVID-19 by measuring arteriovenous thrombocyte differences. We hypothesized that the early stages of the disease would be characterized by a net pulmonary removal of circulating thrombocytes because of immunothrombosis and that later stages would be characterized by a net pulmonary release of thrombocytes as normal pulmonary function is restored.</p><p><strong>Design: </strong>Cohort study with repeated measurements of arterial and central venous thrombocyte counts.</p><p><strong>Setting: </strong>ICU in a large university hospital.</p><p><strong>Patients: </strong>Thirty-one patients with critical COVID-19 that were admitted to the ICU and received invasive or noninvasive mechanical ventilation.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We found a significant positive association between the arteriovenous thrombocyte difference and time since symptom debut. This finding indicates a negative arteriovenous thrombocyte difference and hence pulmonary removal of thrombocytes in the early stages of the disease and a positive arteriovenous thrombocyte difference and hence pulmonary release of thrombocytes in later stages. Most individual arteriovenous thrombocyte differences were smaller than the variance coefficient of the analysis.</p><p><strong>Conclusions: </strong>The results of this study support our hypothesis that early stages of critical COVID-19 are characterized by pulmonary removal of circulating thrombocytes because of immunothrombosis and that later stages are characterized by the return of normal pulmonary release of thrombocytes. However, in most cases, the arteriovenous thrombocyte difference was too small to say anything about pulmonary thrombocyte removal and release on an individual level.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11254116/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141636110","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-08eCollection Date: 2024-07-01DOI: 10.1097/CCE.0000000000001126
Laurent Camous, Jean-David Pommier, Benoît Tressières, Frederic Martino, Mathieu Picardeau, Cecile Loraux, Marc Valette, Hugo Chaumont, Michel Carles, Alexandre Demoule, Sebastien Breurec
Objectives: To identify distinct phenotypes of critically ill leptospirosis patients upon ICU admission and their potential associations with outcome.
Design: Retrospective observational study including all patients with biologically confirmed leptospirosis admitted to the ICU between January 2014 and December 2022. Subgroups of patients with similar clinical profiles were identified by unsupervised clustering (factor analysis for mixed data and hierarchical clustering on principal components).
Setting: All patients admitted to the ICU of the University Hospital of Guadeloupe on the study period.
Patients: One hundred thirty critically ill patients with confirmed leptospirosis were included.
Interventions: None.
Measurements and main results: At ICU admission, 34% of the patients had acute respiratory failure, and 26% required invasive mechanical ventilation. Shock was observed in 52% of patients, myocarditis in 41%, and neurological involvement in 20%. Unsupervised clustering identified three clusters-"Weil's Disease" (48%), "neurological leptospirosis" (20%), and "multiple organ failure" (32%)-with different ICU courses and outcomes. Myocarditis and neurological involvement were key components for cluster identification and were significantly associated with death in ICU. Other factors associated with mortality included shock, acute respiratory failure, and requiring renal replacement therapy.
Conclusions and relevance: Unsupervised analysis of critically ill patients with leptospirosis revealed three patient clusters with distinct phenotypic characteristics and clinical outcomes. These patients should be carefully screened for neurological involvement and myocarditis at ICU admission.
{"title":"Organ Involvement Related to Death in Critically Ill Patients With Leptospirosis: Unsupervised Analysis in a French West Indies ICU.","authors":"Laurent Camous, Jean-David Pommier, Benoît Tressières, Frederic Martino, Mathieu Picardeau, Cecile Loraux, Marc Valette, Hugo Chaumont, Michel Carles, Alexandre Demoule, Sebastien Breurec","doi":"10.1097/CCE.0000000000001126","DOIUrl":"10.1097/CCE.0000000000001126","url":null,"abstract":"<p><strong>Objectives: </strong>To identify distinct phenotypes of critically ill leptospirosis patients upon ICU admission and their potential associations with outcome.</p><p><strong>Design: </strong>Retrospective observational study including all patients with biologically confirmed leptospirosis admitted to the ICU between January 2014 and December 2022. Subgroups of patients with similar clinical profiles were identified by unsupervised clustering (factor analysis for mixed data and hierarchical clustering on principal components).</p><p><strong>Setting: </strong>All patients admitted to the ICU of the University Hospital of Guadeloupe on the study period.</p><p><strong>Patients: </strong>One hundred thirty critically ill patients with confirmed leptospirosis were included.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>At ICU admission, 34% of the patients had acute respiratory failure, and 26% required invasive mechanical ventilation. Shock was observed in 52% of patients, myocarditis in 41%, and neurological involvement in 20%. Unsupervised clustering identified three clusters-\"Weil's Disease\" (48%), \"neurological leptospirosis\" (20%), and \"multiple organ failure\" (32%)-with different ICU courses and outcomes. Myocarditis and neurological involvement were key components for cluster identification and were significantly associated with death in ICU. Other factors associated with mortality included shock, acute respiratory failure, and requiring renal replacement therapy.</p><p><strong>Conclusions and relevance: </strong>Unsupervised analysis of critically ill patients with leptospirosis revealed three patient clusters with distinct phenotypic characteristics and clinical outcomes. These patients should be carefully screened for neurological involvement and myocarditis at ICU admission.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11233108/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141560498","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-07-08eCollection Date: 2024-07-01DOI: 10.1097/CCE.0000000000001124
Ann-Charlotte Lindström, Erik von Oelreich, Jesper Eriksson, Mikael Eriksson, Johan Mårtensson, Emma Larsson, Anders Oldner
Objectives: Exposure to critical illness and intensive care may lead to long-term psychologic and physical impairments. To what extent ICU survivors become prolonged users of benzodiazepines after exposure to critical care is not fully explored. This study aimed to describe the extent of onset of prolonged high-potency benzodiazepine use among ICU survivors not using these drugs before admission, identify factors associated with this use, and analyze whether such usage is associated with increased mortality.
Design: Retrospective cohort study.
Setting: Sweden, including all registered ICU admissions between 2010 and 2017.
Patients: ICU patients surviving for at least 3 months, not using high-potency benzodiazepine before admission, were eligible for inclusion.
Interventions: Admission to intensive care.
Measurements and main results: A total of 237,904 patients were screened and 137,647 were included. Of these 5338 (3.9%) became prolonged users of high-potency benzodiazepines after ICU discharge. A peak in high-potency benzodiazepine prescriptions was observed during the first 3 months, followed by sustained usage throughout the follow-up period of 18 months. Prolonged usage was associated with older age, female sex, and a history of both somatic and psychiatric comorbidities, including substance abuse. Additionally, a longer ICU stay, a high estimated mortality rate, and prior consumption of low-potency benzodiazepines were associated with prolonged use. The risk of death between 6 and 18 months post-ICU admission was significantly higher among high-potency benzodiazepine users, with an adjusted hazard ratio of 1.8 (95% CI, 1.7-2.0; p < 0.001). No differences were noted in causes of death between users and nonusers.
Conclusions: Despite the lack of evidence supporting long-term treatment, prolonged usage of high-potency benzodiazepines 18 months following ICU care was notable and associated with an increased risk of death. Considering the substantial number of ICU admissions, prevention of benzodiazepine misuse may improve long-term outcomes following critical care.
{"title":"Onset of Prolonged High-Potency Benzodiazepine Use Among ICU Survivors: A Nationwide Cohort Study.","authors":"Ann-Charlotte Lindström, Erik von Oelreich, Jesper Eriksson, Mikael Eriksson, Johan Mårtensson, Emma Larsson, Anders Oldner","doi":"10.1097/CCE.0000000000001124","DOIUrl":"10.1097/CCE.0000000000001124","url":null,"abstract":"<p><strong>Objectives: </strong>Exposure to critical illness and intensive care may lead to long-term psychologic and physical impairments. To what extent ICU survivors become prolonged users of benzodiazepines after exposure to critical care is not fully explored. This study aimed to describe the extent of onset of prolonged high-potency benzodiazepine use among ICU survivors not using these drugs before admission, identify factors associated with this use, and analyze whether such usage is associated with increased mortality.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting: </strong>Sweden, including all registered ICU admissions between 2010 and 2017.</p><p><strong>Patients: </strong>ICU patients surviving for at least 3 months, not using high-potency benzodiazepine before admission, were eligible for inclusion.</p><p><strong>Interventions: </strong>Admission to intensive care.</p><p><strong>Measurements and main results: </strong>A total of 237,904 patients were screened and 137,647 were included. Of these 5338 (3.9%) became prolonged users of high-potency benzodiazepines after ICU discharge. A peak in high-potency benzodiazepine prescriptions was observed during the first 3 months, followed by sustained usage throughout the follow-up period of 18 months. Prolonged usage was associated with older age, female sex, and a history of both somatic and psychiatric comorbidities, including substance abuse. Additionally, a longer ICU stay, a high estimated mortality rate, and prior consumption of low-potency benzodiazepines were associated with prolonged use. The risk of death between 6 and 18 months post-ICU admission was significantly higher among high-potency benzodiazepine users, with an adjusted hazard ratio of 1.8 (95% CI, 1.7-2.0; <i>p</i> < 0.001). No differences were noted in causes of death between users and nonusers.</p><p><strong>Conclusions: </strong>Despite the lack of evidence supporting long-term treatment, prolonged usage of high-potency benzodiazepines 18 months following ICU care was notable and associated with an increased risk of death. Considering the substantial number of ICU admissions, prevention of benzodiazepine misuse may improve long-term outcomes following critical care.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11233102/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141565373","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}