Acute and Critical Care

Original Articles

Trauma
Comparison of admission GCS score to admission GCS-P and FOUR scores for prediction of outcomes among patients with traumatic brain injury in the intensive care unit in India: Nishant Agrawal, Shivakumar S Iyer, Vishwanath Patil, Sampada Kulkarni, Jignesh N Shah, Prashant Jedge; Acute Crit Care. 2023;38(2):226-233. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2023.00570

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Abstract PDF: Background
Traumatic brain injury (TBI) is a major contributor to trauma-related mortality and morbidity. Various scoring models have been proposed to evaluate the level of consciousness. The primary objective of this study was to measure the ability of the Full Outline of Unresponsiveness (FOUR) score and the Glasgow Coma Scale Pupil (GCS-P) score in predicting outcomes among TBI patients in terms of the Glasgow Outcome Scale (GOS) at 1 month and 6 months of follow-up.
Methods
Our study was a prospective observational study carried out over a period of 15 months that enrolled 50 patients admitted with TBI to the intensive care unit who fulfilled our inclusion criteria. Pearson’s correlation coefficient was used to correlate coma scales and outcome measures, and the predictive value of these scales was established by receiver operating characteristic (ROC) curve by calculating the area under the ROC curve with 99% confidence interval. All hypotheses were constructed as two-tailed, and P<0.01 was considered significant.
Results
In the present study, the GCS-P and FOUR scores among all patients on admission as well as in the subset of patients who were mechanically ventilated were statistically significant and strongly correlated with patient outcomes. The correlation coefficient of the GCS score compared to GCS-P and FOUR scores was higher and statistically significant. The areas under the ROC curve for the GCS, GCS-P, and FOUR scores and the number of computed tomography abnormalities were 0.912, 0.905, 0.937, and 0.324, respectively.
Conclusions
The GCS, GCS-P, and FOUR scores are all excellent predictors with a strong positive linear correlation with final outcome prediction. In particular, the GCS score has the best correlation with final outcome.

Nephrology
Epidemiology and outcome of an acute kidney injuries in the polytrauma victims admitted at the apex trauma center in Dubai: Bhushan Sudhakar Wankhade, Zeyad Faoor Alrais, Ghaya Zeyad Alrais, Ammar Mohamed Abdel Hadi, Gopala Arun Kumar Naidu, Mohammed Shahid Abbas, Ahmed Tarek Youssef Aboul Kheir, Hasan Hadad, Sundareswaran Sharma, Mohammad Sait; Acute Crit Care. 2023;38(2):217-225. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2023.00388

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Abstract PDF: Background
Polytrauma due to road traffic accidents is one of the common causes of hospital admissions and deaths. Acute kidney injury (AKI) is frequently observed in polytrauma victims. It has a significant impact on patient’s outcomes after polytraumas.
Methods
This is a single-center, retrospective, and observation study done at a tertiary health care center in the state. Polytrauma victims with an Injury Severity Score (ISS) of more than 25 were included in the study.
Results
The incidence of AKI in polytrauma victims is 30.5%. It is common in patients with a higher Carlson comorbidity index (P=0.021). It is more common in patients with higher ISS (P=0.001). On logistic regression, there is good regression between ISS value and AKI (odds ratio [OR], 1.191; 95% confidence interval [CI], 1.150–1.233; P<0.05). The main causes of trauma-induced AKI are hemorrhagic shock (P=0.001), need for massive transfusion (P<0.00), rhabdomyolysis (P=0.001), and abdominal compartment syndrome (ACS; P<0.001). On multivariate logistic regression AKI can be predicated by higher ISS (OR, 1.08; 95% CI, 1.00–1.17; P=0.05) and low mixed venous saturation (OR, 1.13; 95% CI, 1.05–1.22; P<0.001). The development of AKI after polytrauma increases length of stay (LOS)-hospital (P=0.006), LOS-intensive care unit (ICU; P=0.003), need for mechanical ventilation (MV) (P<0.001), ventilator days (P=0.001), and mortality (P<0.001).
Conclusions
The incidence of AKI after polytrauma is about 30.5%. It is more common in a patient with preexisting comorbidities. The frequent causes of AKI after polytrauma are hemorrhagic shock, massive blood transfusion, rhabdomyolysis, and ACS. Although the AKI after polytrauma increases LOS-hospital, LOS-ICU, the need for MV, ventilator days, and mortality, this association may be related to more severe injuries in the AKI group.

CPR/Resuscitation
Percent fluid overload for prediction of fluid de-escalation in critically ill patients in Saudi Arabia: a prospective observational study: Reham A. Alharbi, Namareq F. Aldardeer, Emily L. G. Heaphy, Ahmad H. Alabbasi, Amjad M. Albuqami, Hassan Hawa; Acute Crit Care. 2023;38(2):209-216. Published online May 16, 2023; DOI: https://doi.org/10.4266/acc.2022.01550

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Abstract PDF Supplementary Material: Background
Percent fluid overload greater than 5% is associated with increased mortality. The appropriate time for fluid deresuscitation depends on the patient's radiological and clinical findings. This study aimed to assess the applicability of percent fluid overload calculations for evaluating the need for fluid deresuscitation in critically ill patients.
Methods
This was a single-center, prospective, observational study of critically ill adult patients requiring intravenous fluid administration. Patients who were de-resuscitated with diuretics and/or renal replacement therapy were compared to those who did not need such treatment. The study's primary outcome was median percent fluid accumulation on the day of fluid deresuscitation or intensive care unit (ICU) discharge, whichever came first.
Results
A total of 388 patients was screened between August 1, 2021, and April 30, 2022. Of these, 100 with a mean age of 59.8±16.2 years were included for analysis. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15.4±8.0. Sixty-one patients (61.0%) required fluid deresuscitation during their ICU stay, while 39 (39.0%) did not. Median percent fluid accumulation on the day of deresuscitation or ICU discharge was 4.5% (interquartile range [IQR], 1.7%–9.1%) and 5.2% (IQR, 2.9%–7.7%) in patients requiring deresuscitation and those who did not, respectively (P=not significant). Hospital mortality occurred in 25 (40.9%) of patients with deresuscitation and six (15.3%) patients who did not require it (P=0.007).
Conclusions
The percent fluid accumulation on the day of fluid deresuscitation or ICU discharge was not statistically different between patients who required fluid deresuscitation and those who did not. A larger sample size is needed to confirm these findings.

Pulmonary
Evaluating diaphragmatic dysfunction and predicting non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease in India: Nupur B Patel, Gaurav Jain, Udit Chauhan, Ajeet Singh Bhadoria, Saurabh Chandrakar, Haritha Indulekha; Acute Crit Care. 2023;38(2):200-208. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2022.01060

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Abstract PDF: Background
Baseline diaphragmatic dysfunction (DD) at the initiation of non-invasive ventilation (NIV) correlates positively with subsequent intubation. We investigated the utility of DD detected 2 hours after NIV initiation in estimating NIV failure events in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients.
Methods
In a prospective-cohort design, we enrolled 60 consecutive patients with AECOPD initiated on NIV at intensive care unit admission, and NIV failure events were noted. The DD was assessed at baseline (T1 timepoint) and 2 hours after initiating NIV (T2 timepoint). We defined DD as ultrasound-assessed change in diaphragmatic thickness (ΔTDI) <20% (predefined criteria [PC]) or its cut-off that predicts NIV failure (calculated criteria [CC]) at both timepoints. The receiver operating characteristic curve, chi-square, and regression analyses were reported.
Results
In total, 32 patients developed NIV failure, nine within 2 hours of NIV and the remaining in the next 6 days. The ∆TDI cut-off that predicted NIV failure (DD-CC) at T1 was ≤19.04% (area under the curve [AUC], 0.73; sensitivity, 50%; specificity, 85.71%; accuracy; 66.67%), while that at T2 was ≤35.3% (AUC, 0.75; sensitivity, 95.65%; specificity, 57.14%; accuracy, 74.51%). The NIV failure rate was 35.1% in those with normal diaphragmatic function by PC (T2) versus 5.9% by CC (T2). The odds ratio for NIV failure with DD criteria ≤35.3 and <20 at T2 was 29.33 and 4.61, respectively, while that for ≤19.04 and <20 at T1 was 6. A CC ≤35.3 attained a significantly higher hazard ratio (19.55) and cumulative hazard for NIV failure compared to other thresholds.
Conclusions
The DD criterion of ≤35.3 (T2) had a better diagnostic profile compared to baseline and PC in prediction of NIV failure.

CPR/Resuscitation
Prognostic significance of respiratory quotient in patients undergoing extracorporeal cardiopulmonary resuscitation in Korea: Yun Im Lee, Ryoung-Eun Ko, Soo Jin Na, Jeong-Am Ryu, Yang Hyun Cho, Jeong Hoon Yang, Chi Ryang Chung, Gee Young Suh; Acute Crit Care. 2023;38(2):190-199. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2022.01438

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Abstract PDF: Background
Respiratory quotient (RQ) may be used as a tissue hypoxia marker in various clinical settings but its prognostic significance in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) is not known.
Methods
Medical records of adult patients admitted to the intensive care units after ECPR in whom RQ could be calculated from May 2004 to April 2020 were retrospectively reviewed. Patients were divided into good neurologic outcome and poor neurologic outcome groups. Prognostic significance of RQ was compared to other clinical characteristics and markers of tissue hypoxia.
Results
During the study period, 155 patients were eligible for analysis. Of them, 90 (58.1%) had a poor neurologic outcome. The group with poor neurologic outcome had a higher incidence of out-of-hospital cardiac arrest (25.6% vs. 9.2%, P=0.010) and longer cardiopulmonary resuscitation to pump-on time (33.0 vs. 25.2 minutes, P=0.001) than the group with good neurologic outcome. For tissue hypoxia markers, the group with poor neurologic outcome had higher RQ (2.2 vs. 1.7, P=0.021) and lactate levels (8.2 vs. 5.4 mmol/L, P=0.004) than the group with good neurologic outcome. On multivariable analysis, age, cardiopulmonary resuscitation to pump-on time, and lactate levels above 7.1 mmol/L were significant predictors for a poor neurologic outcome but not RQ.
Conclusions
In patients who received ECPR, RQ was not independently associated with poor neurologic outcome.

Pulmonary
The role of ROX index–based intubation in COVID-19 pneumonia: a cross-sectional comparison and retrospective survival analysis: Sara Vergis, Sam Philip, Vergis Paul, Manjit George, Nevil C Philip, Mithu Tomy; Acute Crit Care. 2023;38(2):182-189. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2022.00206

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Abstract PDF: Background
Coronavirus disease 2019 (COVID-19) patients with acute respiratory failure who experience delayed initiation of invasive mechanical ventilation have poor outcomes. The lack of objective measures to define the timing of intubation is an area of concern. We investigated the effect of timing of intubation based on respiratory rate oxygenation (ROX) index on the outcomes of COVID-19 pneumonia.
Methods
This was a retrospective cross-sectional study performed in a tertiary care teaching hospital in Kerala, India. Patients with COVID-19 pneumonia who were intubated were grouped into early intubation (within 12 hours of ROX index <4.88) or delayed intubation (12 hours or more hours after ROX <4.88).
Results
A total of 58 patients was included in the study after exclusions. Among them, 20 patients were intubated early, and 38 patients were intubated 12 hours after ROX index <4.88. The mean age of the study population was 56.8±13.7 years, and 55.0% of the patients were male; diabetes mellitus (48.3%) and hypertension (50.0%) were the most common comorbidities. The early intubation group had 88.2% successful extubation, while only 11.8% of the delayed group had successful extubation (P<0.001). Survival was also significantly more frequent in the early intubation group.
Conclusions
Early intubation within 12 hours of ROX index <4.88 was associated with improved extubation and survival in patients with COVID-19 pneumonia.

Pulmonary
Relationship between positive end-expiratory pressure levels, central venous pressure, systemic inflammation and acute renal failure in critically ill ventilated COVID-19 patients: a monocenter retrospective study in France: Pierre Basse, Louis Morisson, Romain Barthélémy, Nathan Julian, Manuel Kindermans, Magalie Collet, Benjamin Huot, Etienne Gayat, Alexandre Mebazaa, Benjamin G. Chousterman; Acute Crit Care. 2023;38(2):172-181. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2022.01494

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Abstract PDF Supplementary Material: Background
The role of positive pressure ventilation, central venous pressure (CVP) and inflammation on the occurrence of acute kidney injury (AKI) have been poorly described in mechanically ventilated patient secondary to coronavirus disease 2019 (COVID-19).
Methods
This was a monocenter retrospective cohort study of consecutive ventilated COVID-19 patients admitted in a French surgical intensive care unit between March 2020 and July 2020. Worsening renal function (WRF) was defined as development of a new AKI or a persistent AKI during the 5 days after mechanical ventilation initiation. We studied the association between WRF and ventilatory parameters including positive end-expiratory pressure (PEEP), CVP, and leukocytes count.
Results
Fifty-seven patients were included, 12 (21%) presented WRF. Daily PEEP, 5 days mean PEEP and daily CVP values were not associated with occurrence of WRF. 5 days mean CVP was higher in the WRF group compared to patients without WRF (median [IQR]: 12 mm Hg [11-13] vs. 10 mm Hg [9–12], P=0.03). Multivariate models with adjustment on leukocytes and Simplified Acute Physiology Score (SAPS) II confirmed the association between CVP value and risk of WRF (odd ratio, 1.97; 95% confidence interval, 1.12–4.33). Leukocytes count was also associated with occurrence of WRF in the WRF group (14.3 G/L [11.3–17.5]) and the no-WRF group (9.2 G/L [8.1–11.1]) (P=0.002).
Conclusions
In Mechanically ventilated COVID-19 patients, PEEP levels did not appear to influence occurrence of WRF. High CVP levels and leukocytes count are associated with risk of WRF.

Meta-analysis
Comparison of safety and efficacy between therapeutic or intermediate versus prophylactic anticoagulation for thrombosis in COVID-19 patients: a systematic review and meta-analysis: Hyeon-Jeong Lee, Hye Jin Jang, Won-Il Choi, Joonsung Joh, Junghyun Kim, Jungeun Park, Miyoung Choi; Acute Crit Care. 2023;38(2):160-171. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2022.01424

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Abstract PDF Supplementary Material: Background
Patients with coronavirus disease 2019 (COVID-19) infections often have macrovascular or microvascular thrombosis and inflammation, which are known to be associated with a poor prognosis. Heparin has been hypothesized that administration of heparin with treatment dose rather than prophylactic dose for prevention of deep vein thrombosis in COVID-19 patients.
Methods
Studies comparing therapeutic or intermediate anticoagulation with prophylactic anticoagulation in COVID-19 patients were eligible. Mortality, thromboembolic events, and bleeding were the primary outcomes. PubMed, Embase, the Cochrane Library, and KMbase were searched up to July 2021. A meta-analysis was performed using random-effect model. Subgroup analysis was conducted according to disease severity.
Results
Six randomized controlled trials (RCTs) with 4,678 patients and four cohort studies with 1,080 patients were included in this review. In the RCTs, the therapeutic or intermediate anticoagulation was associated with significant reductions in the occurrence of thromboembolic events (5 studies, n=4,664; relative risk [RR], 0.72; P=0.01), and a significant increase in bleeding events (5 studies, n=4,667; RR, 1.88; P=0.004). In the moderate patients, therapeutic or intermediate anticoagulation was more beneficial than prophylactic anticoagulation in terms of thromboembolic events, but showed significantly higher bleeding events. In the severe patients, the incidence of thromboembolic and bleeding events in the therapeutic or intermediate.
Conclusions
The study findings suggest that prophylactic anticoagulant treatment should be used in patients with moderate and severe COVID-19 infection groups. Further studies are needed to determine more individualized anticoagulation guidance for all COVID-19 patients.

Gastroenterology
The diagnostic accuracy of ultrasonography over manual aspiration for gastric reserve volume estimation in critically ill patients: Rahul Sharma, Ravi Kant Dogra, Jyoti Pathania, Arti Sharma; Acute Crit Care. 2023;38(1):134-141. Published online February 22, 2023; DOI: https://doi.org/10.4266/acc.2022.00955

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Abstract PDF: Background
Although gastric reserve volume (GRV) is a surrogate marker of gastrointestinal dysfunction and feeding intolerance, there is ambiguity in its estimation due to problems associated with its measurement. Introduction of point-of-care ultrasound as a tool for anesthetists kindled interest in its use for GRV estimation. Methods: In this prospective observational study, we recruited 57 critically ill patients and analyzed 586 samples of GRV obtained by both ultrasonography (USG) and manual aspiration. Results: The analysis showed that USG-guided GRV was significantly correlated (r=0.788, P<0.001) and in positive agreement with manual aspiration based on Bland-Altman plot, with a mean difference of 8.50±14.84 (95% confidence interval, 7.389–9.798). The upper and lower limits of agreement were 37.7 and –20.5, respectively, within the ±1.96 standard deviation (P<0.001). The respective sensitivity and positive predictive value, specificity and negative predictive value, and area under the curve of USG for feeding intolerance were 66.67%, 98.15%, and 0.82%, with 96.49% diagnostic accuracy. Conclusions: Ultrasonographic estimation of GRV was positively, significantly correlated and in agreement with the manual aspiration method and estimated feeding intolerance earlier. Routine use of gastric USG could avoid clinical situations where feeding status is unclear and there is high risk of aspiration and could become a standard practice of critical care.

Liver
Alcohol use disorder in the intensive care unit a highly morbid condition, but chemical dependency discussion improves outcomes: Kristin Colling, Alexandra K. Kraft, Melissa L. Harry; Acute Crit Care. 2023;38(1):122-133. Published online January 10, 2023; DOI: https://doi.org/10.4266/acc.2022.00584

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Abstract PDF: Background
Alcohol use disorders (AUD) are common in patients admitted to intensive care units (ICU) and increase the risk for worse outcomes. In this study, we describe factors associated with patient mortality after ICU admission and the effect of chemical dependency (CD) counseling on outcomes in the year following ICU admission. Methods: We retrospectively reviewed patient demographics, hospital data, and documentation of CD counseling by medical providers for all ICU patients with AUD admitted to our institution between January 2017 and March 2019. Primary outcomes were in-hospital and 1-year mortality. Results: Of the 527 patients with AUD requiring ICU care, median age was 56 years (range, 18–86). Both in-hospital (12%) and 1-year mortality rates (27%) were high. Rural patients, comorbidities, older age, need for mechanical ventilation, and complications were associated with increased risk of in-hospital and 1-year mortality. CD counseling was documented for 73% of patients, and 50% of these patients accepted alcohol treatment or resources prior to discharge. CD evaluation and acceptance was associated with a significantly decreased rate of readmission for liver or alcohol-related issues (36% vs. 58%; odds ratio [OR], 0.41; 95% confidence interval [CI], 0.27–0.61) and 1-year mortality (7% vs. 19.5%; OR, 0.32; 95% CI, 0.16–0.64). CD evaluation alone, regardless of patient acceptance, was associated with a significantly decreased 1-year post-discharge mortality rate (12% vs. 23%; OR, 0.44; 95% CI, 0.25–0.77). Conclusions: ICU patients with AUD had high in-hospital and 1-year mortality. CD evaluation, regardless of patient acceptance, was associated with a significant decrease in 1-year mortality

Trauma
Association of Glasgow coma scale and endotracheal intubation in predicting mortality among patients admitted to the intensive care unit: Nader Markazi Moghaddam, Mohammad Fathi, Sanaz Zargar Balaye Jame, Mohammad Darvishi, Morteza Mortazavi; Acute Crit Care. 2023;38(1):113-121. Published online February 22, 2023; DOI: https://doi.org/10.4266/acc.2022.00927

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Abstract PDF: Background
We assessed predictors of mortality in the intensive care unit (ICU) and investigated if Glasgow coma scale (GCS) is associated with mortality in patients undergoing endotracheal intubation (EI). Methods: From February 2020, we performed a 1-year study on 2,055 adult patients admitted to the ICU of two teaching hospitals. The outcome was mortality during ICU stay and the predictors were patients’ demographic, clinical, and laboratory features. Results: EI was associated with a decreased risk for mortality compared with similar patients (adjusted odds ratio [AOR], 0.32; P=0.030). This shows that EI had been performed correctly with proper indications. Increasing age (AOR, 1.04; P<0.001) or blood pressure (AOR, 1.01; P<0.001), respiratory problems (AOR, 3.24; P<0.001), nosocomial infection (AOR, 1.64; P=0.014), diabetes (AOR, 5.69; P<0.001), history of myocardial infarction (AOR, 2.52; P<0.001), chronic obstructive pulmonary disease (AOR, 3.93; P<0.001), immunosuppression (AOR, 3.15; P<0.001), and the use of anesthetics/sedatives/hypnotics for reasons other than EI (AOR, 4.60; P<0.001) were directly; and GCS (AOR, 0.84; P<0.001) was inversely related to mortality. In patients with trauma surgeries (AOR, 0.62; P=0.014) or other surgical categories (AOR, 0.61; P=0.024) undergoing EI, GCS had an inverse relation with mortality (accuracy=82.6%, area under the receiver operator characteristic curve=0.81). Conclusions: A variety of features affected the risk for mortality in patients admitted to the ICU. Considering GCS score for EI had the potential of affecting prognosis in subgroups of patients such as those with trauma surgeries or other surgical categories.

CPR/Resuscitation
Lower limb muscle matters in patients with hypoxic brain injury following out-of-hospital cardiac arrest: Dong-Hyun Jang, Seung Min Park, Dong Keon Lee, Dong Won Kim, Chang Woo Im, You Hwan Jo, Kui Ja Lee; Acute Crit Care. 2023;38(1):104-112. Published online February 27, 2023; DOI: https://doi.org/10.4266/acc.2022.01389

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Abstract PDF Supplementary Material: Background
There are conflicting results regarding the association between body mass index and the prognosis of cardiac arrest patients. We investigated the association of the composition and distribution of muscle and fat with neurologic outcomes at hospital discharge in successfully resuscitated out-of-hospital cardiac arrest (OHCA) patients. Methods: This prospective, single-centre, observational study involved adult OHCA patients, conducted between April 2019 and June 2021. The ratio of total skeletal muscle, upper limb muscle, lower limb muscle, and total fat to body weight was measured using InBody S10, a bioimpedance analyser, after achieving the return of spontaneous circulation. Restricted cubic spline curves with four knots were used to examine the relationship between total skeletal muscle, upper limb muscle, and lower limb muscle relative to total body weight and neurologic outcome at discharge. Multivariable logistic regression analysis was performed to assess an independent association. Results: A total of 66 patients were enrolled in the study. The proportion of total muscle and lower limb muscle positively correlated with the possibility of having a good neurologic outcome. The proportion of lower limb muscle showed an independent association in the multivariable analysis (adjusted odds ratio, 2.29; 95% confidence interval, 1.06–13.98), and its optimal cut-off value calculated through receiver operating characteristic curve analysis was 23.1%, which can predict a good neurological outcome. Conclusions: A higher proportion of lower limb muscle to body weight was independently associated with the probability of having a good neurologic outcome in OHCA patients.

Trauma
Selection of appropriate reference creatinine estimate for acute kidney injury diagnosis in patients with severe trauma: Kangho Lee, Dongyeon Ryu, Hohyun Kim, Sungjin Park, Sangbong Lee, Chanik Park, Gilhwan Kim, Sunhyun Kim, Nahyeon Lee; Acute Crit Care. 2023;38(1):95-103. Published online February 27, 2023; DOI: https://doi.org/10.4266/acc.2022.01046

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Abstract PDF: Background
In patients with severe trauma, the diagnosis of acute kidney injury (AKI) is important because it is a predictive factor for poor prognosis and can affect patient care. The diagnosis and staging of AKI are based on change in serum creatinine (SCr) levels from baseline. However, baseline creatinine levels in patients with traumatic injuries are often unknown, making the diagnosis of AKI in trauma patients difficult. This study aimed to enhance the accuracy of AKI diagnosis in trauma patients by presenting an appropriate reference creatinine estimate (RCE). Methods: We reviewed adult patients with severe trauma requiring intensive care unit admission between 2015 and 2019 (n=3,228) at a single regional trauma center in South Korea. AKI was diagnosed based on the current guideline published by the Kidney Disease: Improving Global Outcomes organization. AKI was determined using the following RCEs: estimated SCr75-modification of diet in renal disease (MDRD), trauma MDRD (TMDRD), admission creatinine level, and first-day creatinine nadir. We assessed inclusivity, prognostic ability, and incrementality using the different RCEs. Results: The incidence of AKI varied from 15% to 46% according to the RCE used. The receiver operating characteristic curve of TMDRD used to predict mortality and the need for renal replacement therapy (RRT) had the highest value and was statistically significant (0.797, P<0.001; 0.890, P=0.002, respectively). In addition, the use of TMDRD resulted in a mortality prognostic ability and the need for RRT was incremental with AKI stage. Conclusions: In this study, TMDRD was feasible as a RCE, resulting in optimal post-traumatic AKI diagnosis and prognosis.

Nephrology
Impact of intradialytic hypotension on mortality following the transition from continuous renal replacement therapy to intermittent hemodialysis: Seong Geun Kim, Donghwan Yun, Jinwoo Lee, Yong Chul Kim, Dong Ki Kim, Kook-Hwan Oh, Kwon Wook Joo, Yon Su Kim, Seung Seok Han; Acute Crit Care. 2023;38(1):86-94. Published online October 26, 2022; DOI: https://doi.org/10.4266/acc.2022.00948

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Abstract PDF: Background
The transition of dialysis modalities from continuous renal replacement therapy (CRRT) to intermittent hemodialysis (iHD) is frequently conducted during the recovery phase of critically ill patients with acute kidney injury. Herein, we addressed the occurrence of intradialytic hypotension (IDH) after this transition, and its association with the mortality risk. Methods: A total of 541 patients with acute kidney injury who attempted to transition from CRRT to iHD at Seoul National University Hospital, Korea from 2010 to 2020 were retrospectively collected. IDH was defined as a discontinuation of dialysis because of hemodynamic instability plus a nadir systolic blood pressure <90 mm Hg or a decrease in systolic blood pressure ≥30 mm Hg during the first session of iHD. Odds ratios (ORs) of outcomes, such as in-hospital mortality and weaning from RRT, were measured using a logistic regression model after adjusting for multiple variables. Results: IDH occurred in 197 patients (36%), and their mortality rate (44%) was higher than that of those without IDH (19%; OR, 2.64; 95% confidence interval [CI], 1.70–4.08). For patients exhibiting IDH, the iHD sessions delayed successful weaning from RRT (OR, 0.62; 95% CI, 0.43–0.90) compared with sessions on those without IDH. Factors such as low blood pressure, high pulse rate, low urine output, use of mechanical ventilations and vasopressors, and hypoalbuminemia were associated with IDH risk. Conclusions: IDH occurrence following the transition from CRRT to iHD is associated with high mortality and delayed weaning from RRT.

Infection
Study of the gut microbiome as a novel target for prevention of hospital-associated infections in intensive care unit patients: Suzan Ahmed Elfiky, Shwikar Mahmoud Ahmed, Ahmed Mostafa Elmenshawy, Gehad Mahmoud Sultan, Sara Lotfy Asser; Acute Crit Care. 2023;38(1):76-85. Published online February 23, 2023; DOI: https://doi.org/10.4266/acc.2022.01116

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Abstract PDF: Background
Hospital-acquired infections (HAIs) are increasing due to the spread of multi-drugresistant organisms. Gut dysbiosis in an intensive care unit (ICU) patients at admission showed an altered abundance of some bacterial genera associated with the occurrence of HAIs and mortality. In the present study, we investigated the pattern of the gut microbiome in ICU patients at admission to correlate it with the development of HAIs during ICU stay. Methods: Twenty patients admitted to an ICU with a cross-matched control group of 30 healthy subjects of matched age and sex. Quantitative SYBR green real-time polymerase chain reaction was done for the identification and quantitation of selected bacteria. Results: Out of those twenty patients, 35% developed ventilator-associated pneumonia during their ICU stay. Gut microbiome analysis showed a significant decrease in Firmicutes and Firmicutes to Bacteroidetes ratio in ICU patients in comparison to the control and in patients who developed HAIs in comparison to the control group and patients who did not develop HAIs. There was a statistically significant increase in Bacteroides in comparison to the control group. There was a statistically significant decrease in Bifidobacterium and Faecalibacterium prausnitzii and an increase in Lactobacilli in comparison to the control group with a negative correlation between Acute Physiology and Chronic Health Evaluation (APACHE) II score and Firmicutes to Bacteroidetes and Prevotella to Bacteroides ratios. Conclusions: Gut dysbiosis of patients at the time of admission highlights the importance of identification of the microbiome of patients admitted to the ICU as a target for preventing of HAIs

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