Acute and Critical Care

Volume 37 (3); August 2022

Review Article

Neurology
Transient splenial lesions of the corpus callosum and infectious diseases: Kyu Sun Yum, Dong-Ick Shin; Acute Crit Care. 2022;37(3):269-275. Published online August 17, 2022; DOI: https://doi.org/10.4266/acc.2022.00864

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Abstract PDF: comTransient splenial lesion of the corpus callosum can be observed in various diseases such as cancer, drug use, metabolic disorders, and cerebrovascular disorders, as well as in patients with infectious diseases. During the coronavirus disease 2019 (COVID-19) pandemic, there were increasing reports of these lesions being detected on brain imaging tests performed in patients with neurological symptoms. On brain magnetic resonance imaging, findings suggestive of cytotoxic edema are observed in the splenium; these are known to disappear with improvement of clinical symptoms. Cytokinopathy caused by infection increases the permeability of the blood–brain barrier and activates the glial cells of the brain to induce cytotoxic edema. Most patients have a good prognosis. The causes, mechanism, diagnosis, treatment and prognosis of transient splenial lesions of the corpus callosum will be summarized in this review.

Original Articles

Neurology
Early assessment of aspiration risk in acute stroke by fiberoptic endoscopy in critically ill patients: Mohamed Saad Abdelaziz Elsyaad, Akram Muhammad Fayed, Mohamed Mostafa Abdel Salam Megahed, Nesrine Hazem Hamouda, Ahmed Moustafa Elmenshawy; Acute Crit Care. 2022;37(3):276-285. Published online June 27, 2022; DOI: https://doi.org/10.4266/acc.2021.01375

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Background
Fiberoptic endoscopic evaluation of swallowing (FEES) has been recommended to assess aspiration in stroke. This study aimed to determine the diagnostic and prognostic roles of FEES in the early assessment of aspiration, intensive care unit (ICU) stay and mortality in acute stroke patients.
Methods
Fifty-two patients with acute stroke admitted to the Alexandria Main University Hospital were included. Complete examinations and assessment of aspiration using the 8-point penetration-aspiration scale (PAS) with FEES protocol were performed.
Results
The patients were classified into three groups: normal with no or low risk of aspiration (n=15, 27.3%; PAS level 1), low to moderate risk (n=8, 14.5%; PAS level 2–4), and high risk (n=32, 58.2%; PAS ≥5). There was high incidence of aspiration pneumonia, prolonged ICU stay, and mortality in both moderate- and high-risk groups (P=0.001, P<0.001, and P<0.001, respectively). The PAS score predicted aspiration pneumonia (hospital-acquired pneumonia) with sensitivity and specificity of 80.0% and 76.0%, respectively (negative predictive value [NPV], 76.0; positive predictive value [PPV], 80.0; 95% confidence interval [CI], 0.706–0.940) and mortality with sensitivity and specificity of 88.46% and 68.97% (NPV, 87.0; PPV, 71.9; 95% CI, 0.749–0.951). The PAS score could predict the length of ICU stay with sensitivity and specificity of 70.21% and 87.50, respectively (NPV, 33.3; PPV, 97.1; 95% CI, 0.605–0.906).
Conclusions
The standard FEES protocol using PAS score is a useful tool to assess aspiration in acute stroke patients and could be used to predict length of ICU stay and mortality.

Citations

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The use of videofluoroscopy (VFS) and fibreoptic endoscopic evaluation of swallowing (FEES) in the investigation of oropharyngeal dysphagia in stroke patients: A narrative review
K. Helliwell, V.J. Hughes, C.M. Bennion, A. Manning-Stanley
Radiography.2023; 29(2): 284. CrossRef

Nursing
Improving mobility in the intensive care unit with a protocolized, early mobilization program: observations of a single center before-and-after the implementation of a multidisciplinary program: Laptin Ho, Joe Hin Cheung Tsang, Emmanuel Cheung, Wing Yan Chan, Ka Wai Lee, Sweetie R Lui, Chung Yau Lee, Alfred Lok Hang Lee, Philip Koon Ngai Lam; Acute Crit Care. 2022;37(3):286-294. Published online June 29, 2022; DOI: https://doi.org/10.4266/acc.2021.01564

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Background
Early intensive care unit (ICU) protocolized rehabilitative programs have been described previously, yet with differing starting time points and mostly on mechanically ventilated patients. We extended the concept to all admitted ICU patients and investigate the efficacy of early mobilization in improving mobility of the critically ill, address issues surrounding the timing and intensity of an early rehabilitative program.
Methods
Prospective cohorts of patients admitted consecutively before-and-after (control, n=92; intervention, n=90) the introduction of an early mobilization program in a single center, general hospital ICU. Improvement in mobility as assessed by ICU mobility score, on ICU admission and upon ICU discharge, was measured as a primary outcome.
Results
Those receiving early mobilization in the intensive care unit had higher ICU mobility score (2.63; 95% confidence interval, 0.65–4.61; P<0.001) upon discharge from the intensive care, with earlier out of bed mobilization on day 5 compared to the control group of day 21 (P<0.001). No differences were found in terms of mortality, intensive care hospitalization and subsequent hospitalization duration after discharge from ICU.
Conclusions
Here, we report that improvement in mobility score earlier in the course of intensive care hospitalization with the introduction of a protocolized early rehabilitative program.

Citations

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Early Active Mobilization during Mechanical Ventilation in the ICU

New England Journal of Medicine.2023; 388(6): 572. CrossRef

Neurology
Muscle Growth and Anabolism in Intensive Care Survivors (GAINS) trial: a pilot randomised controlled trial: Matthew H Anstey, Rashmi Rauniyar, Ethan Fitzclarence, Natalie Tran, Emma Osnain, Bianca Mammana, Angela Jacques, Robert N Palmer, Andrew Chapman, Bradley Wibrow; Acute Crit Care. 2022;37(3):295-302. Published online June 27, 2022; DOI: https://doi.org/10.4266/acc.2021.01767

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Abstract PDF Supplementary Material: Background
To explore the feasibility, safety, and potential benefits of administration of the anabolic steroid nandrolone to patients in the recovery phase from critical illness weakness.
Methods
In this phase II, double blind, randomized, controlled trial, adult critically ill patients admitted to one of two tertiary Intensive Care Units in Western Australia for longer than 7 days with significant weakness were enrolled. Patients received nandrolone (200 mg males, 100 mg females) intramuscularly or placebo weekly for up to 3 weeks in addition to standard care. The primary outcome measures were improvement in grip strength, Medical Research Council muscle strength sum score, and functional activity level (Chelsea critical care assessment tool [CPAx]).
Results
A total of 22 patients was enrolled between September 2017 and May 2019. No significant adverse events were detected. Median grip strength change was non-significantly greater in the nandrolone group (8.5 vs. 13.0, P=0.185), while hospital length of stay (36 vs. 26 days, P=0.023) and duration of mechanical ventilation (377 vs. 168, P=0.032) were lower. The discharge CPAx and intensive care unit mobility scores were higher in the nandrolone group, although there was no difference in the change in CPAx score (17.0 vs. 17.7, P=0.865). There were no changes in ultrasound-detected muscle thickness between the two groups.
Conclusions
In patients with prolonged critical illness, nandrolone appears to be safe. However, a larger study, potentially combined with resistance exercise, is needed to definitively address the potential benefits of nandrolone.

Infection
In-hospital mortality prediction using frailty scale and severity score in elderly patients with severe COVID-19: Yong Sub Na, Jin Hyoung Kim, Moon Seong Baek, Won-Young Kim, Ae-Rin Baek, Bo young Lee, Gil Myeong Seong, Song-I Lee; Acute Crit Care. 2022;37(3):303-311. Published online July 5, 2022; DOI: https://doi.org/10.4266/acc.2022.00017

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Background
Elderly patients with coronavirus disease 2019 (COVID-19) have a high disease severity and mortality. However, the use of the frailty scale and severity score to predict in-hospital mortality in the elderly is not well established. Therefore, in this study, we investigated the use of these scores in COVID-19 cases in the elderly.
Methods
This multicenter retrospective study included severe COVID-19 patients admitted to seven hospitals in Republic of Korea from February 2020 to February 2021. We evaluated patients’ Acute Physiology and Chronic Health Evaluation (APACHE) II score; confusion, urea nitrogen, respiratory rate, blood pressure, 65 years of age and older (CURB-65) score; modified early warning score (MEWS); Sequential Organ Failure Assessment (SOFA) score; clinical frailty scale (CFS) score; and Charlson comorbidity index (CCI). We evaluated the predictive value using receiver operating characteristic (ROC) curve analysis.
Results
The study included 318 elderly patients with severe COVID-19 of whom 237 (74.5%) were survivors and 81 (25.5%) were non-survivors. The non-survivor group was older and had more comorbidities than the survivor group. The CFS, CCI, APACHE II, SOFA, CURB-65, and MEWS scores were higher in the non-survivor group than in the survivor group. When analyzed using the ROC curve, SOFA score showed the best performance in predicting the prognosis of elderly patients (area under the curve=0.766, P<0.001). CFS and SOFA scores were associated with in-hospital mortality in the multivariate analysis.
Conclusions
The SOFA score is an efficient tool for assessing in-hospital mortality in elderly patients with severe COVID-19.

Citations

Citations to this article as recorded by

Omicron, Long-COVID, and the Safety of Elective Surgery for Adults and Children: Joint Guidance from the Therapeutics and Guidelines Committee of the Surgical Infection Society and the Surgery Strategic Clinical Network, Alberta Health Services
Philip S. Barie, Mary E. Brindle, Rachel G. Khadaroo, Tara L. Klassen, Jared M. Huston
Surgical Infections.2023; 24(1): 6. CrossRef
Evaluation of risk scores as predictors of mortality and hospital length of stay for older COVID ‐19 patients
Banu Buyukaydin, Tahsin Karaaslan, Omer Uysal
AGING MEDICINE.2023; 6(1): 56. CrossRef
Atypical presentation of COVID-19 in older patients is associated with frailty but not with adverse outcomes
Joy E. van Son, Elisabeth C. P. Kahn, Jessica M. van der Bol, Dennis G. Barten, Laura C. Blomaard, Carmen van Dam, Jacobien Ellerbroek, Steffy W. M. Jansen, Anita Lekx, Carolien M. J. van der Linden, Roy Looman, Huub A. A. M. Maas, Francesco U. S. Mattace
European Geriatric Medicine.2023; 14(2): 333. CrossRef

Infection
Risk factors associated with development of coinfection in critically Ill patients with COVID-19: Erica M. Orsini, Gretchen L. Sacha, Xiaozhen Han, Xiaofeng Wang, Abhijit Duggal, Prabalini Rajendram; Acute Crit Care. 2022;37(3):312-321. Published online August 29, 2022; DOI: https://doi.org/10.4266/acc.2022.00136

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Abstract PDF: Background
At outset of the coronavirus disease 2019 (COVID-19) pandemic, the significance of bacterial and fungal coinfections in individuals with COVID-19 was unknown. Initial reports indicated that the prevalence of coinfection in the general population was low, but there was uncertainty regarding the risk of coinfection in critically ill patients.
Methods
Nine hundred critically ill adult patients with COVID-19 infection were enrolled in this observational case-control study. Patients with a coinfection (case) and patients without a coinfection (control) were compared using univariate and multivariable analyses. A subgroup analysis was performed on patients with coinfection, dividing them into early (infection within 7 days) and late (infection after 7 days) infection groups.
Results
Two hundred and thirty-three patients (25.9%) had a bacterial or fungal coinfection. Vasopressor use (P<0.001) and severity of illness (higher Acute Physiology and Chronic Health Evaluation III score, P=0.009) were risk factors for the development of a coinfection. Patients with coinfection had higher mortality and length of stay. Vasopressor and corticosteroid use and central line and foley catheter placement were risk factors for late infection (>7 days). There were high rates of drug-resistant infections.
Conclusions
Critically ill patients with COVID-19 are at risk for both community-acquired and hospital-acquired infections throughout their hospitalization for COVID-19. It is important to consider the development of a coinfection in clinically worsening critically ill patients with COVID-19 and consider the likelihood of drug-resistance when choosing an empiric regimen.

Pulmonary
Effect of prone positioning on gas exchange according to lung morphology in patients with acute respiratory distress syndrome: Na Young Kim, Si Mong Yoon, Jimyung Park, Jinwoo Lee, Sang-Min Lee, Hong Yeul Lee; Acute Crit Care. 2022;37(3):322-331. Published online July 29, 2022; DOI: https://doi.org/10.4266/acc.2022.00367

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Abstract PDF Supplementary Material: Background
There are limited data on the clinical effects of prone positioning according to lung morphology. We aimed to determine whether the gas exchange response to prone positioning differs according to lung morphology.
Methods
This retrospective study included adult patients with moderate-to-severe acute respiratory distress syndrome (ARDS). The lung morphology of ARDS was assessed by chest computed tomography scan and classified as “diffuse” or “focal.” The primary outcome was change in partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio after the first prone positioning session: first, using the entire cohort, and second, using subgroups of patients with diffuse ARDS matched 2 to 1 with patients with focal ARDS at baseline.
Results
Ninety-five patients were included (focal ARDS group, 23; diffuse ARDS group, 72). Before prone positioning, the focal ARDS group showed worse oxygenation than the diffuse ARDS group (median PaO2/FiO2 ratio, 79.9 mm Hg [interquartile range (IQR)], 67.7–112.6 vs. 104.0 mm Hg [IQR, 77.6–135.7]; P=0.042). During prone positioning, the focal ARDS group showed a greater improvement in the PaO2/FiO2 ratio than the diffuse ARDS group (median, 55.8 mm Hg [IQR, 11.1–109.2] vs. 42.8 mm Hg [IQR, 11.6–83.2]); however, the difference was not significant (P=0.705). Among the PaO2/FiO2-matched cohort, there was no significant difference in change in PaO2/FiO2 ratio after prone positioning between the groups (P=0.904).
Conclusions
In patients with moderate-to-severe ARDS, changes in PaO2/FiO2 ratio after prone positioning did not differ according to lung morphology. Therefore, prone positioning can be considered as soon as indicated, regardless of ARDS lung morphology.

Nutrition
Association of nutrition risk screening 2002 and Malnutrition Universal Screening Tool with COVID-19 severity in hospitalized patients in Iran: Ghazaleh Eslamian, Sohrab Sali, Mansour Babaei, Karim Parastouei, Dorsa Arman Moghadam; Acute Crit Care. 2022;37(3):332-338. Published online July 5, 2022; DOI: https://doi.org/10.4266/acc.2021.01830

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Background
Malnutrition affects normal body function and is associated with disease severity and mortality. Due to the high prevalence of malnutrition reported in patients with coronavirus disease 2019 (COVID-19), the current study examined the association between malnutrition and disease severity in hospitalized adult patients with COVID-19 in Iran.
Methods
In this prospective observational study, 203 adult patients with COVID-19 verified by real-time polymerase chain reaction test and chest computed tomography were recruited from those admitted to a university hospital in Iran. To determine COVID-19 intensity, patients were categorized into four groups. Malnutrition assessment was based on the Malnutrition Universal Screening Tool (MUST) and nutrition risk screening score (NRS-2002). An ordinal regression model was run to assess the association between malnutrition and disease severity.
Results
In the studies sample of Iranian patients with COVID-19, 38.3% of patients had severe COVID-19. According to NRS-2002, 12.9% of patients were malnourished. Based on MUST, 2% of patients were at medium, and 13.4% of patients were at high risk of malnutrition. Malnutrition was associated with a higher odds of extremely severe COVID-19 according to NRS-2002 (odds ratio, 1.38; 95% confidence interval, 0.21–2.56; P=0.021).
Conclusions
Malnutrition was not prevalent in the studies sample of Iranian patients with COVID-19; however, it was associated with a higher odds of extremely severe COVID-19.

Citations

Citations to this article as recorded by

Predictive value of multiple variable models including nutritional risk score (NRS 2002) on mortality and length of stay of patients with covid-19 infections. The INCOVO study
Ghadamieh Fatemeh, Ginette Fotsing, Pedro Marques-Vidal, Peter Kopp, Mohammed Barigou
Clinical Nutrition ESPEN.2023; 55: 357. CrossRef

Epidemiology
The fourth wave: vaccination status and intensive care unit mortality at a large hospital system in New York City: Pranai Tandon, Evan Leibner, Anna Hackett, Katherine Maguire, Kayla Leonardi, Matthew A. Levin, Roopa Kohli-Seth; Acute Crit Care. 2022;37(3):339-346. Published online August 29, 2022; DOI: https://doi.org/10.4266/acc.2022.00675

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Abstract PDF

Background
We aim to describe the demographics and outcomes of patients with severe disease with the Omicron variant. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus continues to mutate, and the availability of vaccines and boosters continue to rise, it is important to understand the health care burden of new variants. We analyze patients admitted to intensive care units (ICUs) in a large Academic Health System during New York City’s fourth surge beginning on November 27, 2021.
Methods
All patients admitted to an ICU were included in the primary analysis. Key demographics and outcomes were retrospectively compared between patients stratified by vaccination status. Univariate and multivariate logistic regression was used to identify risk factors for in-hospital mortality.
Results
In-hospital mortality for all admitted patients during the fourth wave was significantly lower than in previous waves. However, among patients requiring intensive care, in-hospital mortality was high across all levels of vaccination status. In a multivariate model older age was associated with increased in-hospital mortality, vaccination status of overdue for booster was associated with decreased in hospital mortality, and vaccination status of up-to-date with vaccination showed a trend to reduced mortality.
Conclusions
In-hospital mortality of patients with severe respiratory failure from coronavirus disease 2019 (COVID-19) remains high despite decreasing overall mortality. Vaccination against SARS-CoV-2 was protective against mortality. Vaccination remains the best and safest way to protect against serious illness and death from COVID-19. It remains unclear that any other treatment will have success in changing the natural history of the disease.

Citations

Citations to this article as recorded by

Outcomes of Elderly Patients Hospitalized with the SARS-CoV-2 Omicron B.1.1.529 Variant: A Systematic Review
Roxana Manuela Fericean, Cristian Oancea, Akash Reddy Reddyreddy, Ovidiu Rosca, Felix Bratosin, Vlad Bloanca, Cosmin Citu, Satish Alambaram, Neeharika Gayatri Vasamsetti, Catalin Dumitru
International Journal of Environmental Research and Public Health.2023; 20(3): 2150. CrossRef

Pulmonary
The role of diaphragmatic thickness measurement in weaning prediction and its comparison with rapid shallow breathing index: a single-center experience: Lokesh Kumar Lalwani, Manjunath B Govindagoudar, Pawan Kumar Singh, Mukesh Sharma, Dhruva Chaudhry; Acute Crit Care. 2022;37(3):347-354. Published online July 25, 2022; DOI: https://doi.org/10.4266/acc.2022.00108

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Abstract PDF Supplementary Material: Background
Acute respiratory failure (ARF) is commonly managed with invasive mechanical ventilation (IMV). The majority of the time that a patient spends on IMV is in the process of weaning. Prediction of the weaning outcome is of paramount importance, as untimely/delayed extubation is associated with a high risk of mortality. Diaphragmatic ultrasonography is a promising tool in the intensive care unit, and its utility in predicting the success of weaning remains understudied.
Methods
In this prospective-observational study, we recruited 54 ARF patients on IMV, along with 50 healthy controls. During a spontaneous breathing trial, all subjects underwent diaphragmatic ultrasonography along with a rapid shallow breathing index (RSBI) assessment.
Results
The mean age was 41.8±17.0 and 37.6±10.5 years among the cases and control group, respectively. Demographic variables were broadly similar in the two groups. The most common cause of ARF was obstructive airway disease. The average duration of IMV was 5.41±2.81 days. Out of 54 subjects, 45 were successfully weaned, while nine patients failed weaning. Age, body mass index, and severity of disease were similar in the successful and failed weaning patients. The sensitivity in predicting successful weaning of percent change in diaphragmatic thickness (Δtdi%) >29.71% was high (93.33%), while specificity was 66.67%. The sensitivity and specificity of mean diaphragmatic thickness (tdi) end-expiratory >0.178 cm was 60.00% and 77.78%, respectively. RSBI at 1 minute of <93.75 had an equally high sensitivity (93.33%) but a lower specificity (22.22%). Similar results were also found for RSBI measured at 5 minutes.
Conclusions
During the weaning assessment, the purpose is to minimize both premature as well as delayed extubation. We found that diaphragmatic ultrasonography, in particular Δtdi%, is better than RSBI in predicting weaning outcomes.

Liver
Early mechanical ventilation for grade IV hepatic encephalopathy is associated with increased mortality among patients with cirrhosis: an exploratory study: Saad Saffo, Guadalupe Garcia-Tsao; Acute Crit Care. 2022;37(3):355-362. Published online August 18, 2022; DOI: https://doi.org/10.4266/acc.2022.00528

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Abstract PDF

Background
Unresponsive patients with toxic-metabolic encephalopathies often undergo endotracheal intubation for the primary purpose of preventing aspiration events. However, among patients with pre-existing systemic comorbidities, mechanical ventilation itself may be associated with numerous risks such as hypotension, aspiration, delirium, and infection. Our primary aim was to determine whether early mechanical ventilation for airway protection was associated with increased mortality in patients with cirrhosis and grade IV hepatic encephalopathy.
Methods
The National Inpatient Sample was queried for hospital stays due to grade IV hepatic encephalopathy among patients with cirrhosis between 2016 and 2019. After applying our exclusion criteria, including cardiopulmonary failure, data from 1,975 inpatient stays were analyzed. Patients who received mechanical ventilation within 2 days of admission were compared to those who did not. Univariable and multivariable logistic regression analyses were performed to identify clinical factors associated with in-hospital mortality.
Results
Of 162 patients who received endotracheal intubation during the first 2 hospital days, 64 (40%) died during their hospitalization, in comparison to 336 (19%) of 1,813 patients in the comparator group. In multivariable logistic regression analysis, mechanical ventilation was the strongest predictor of in-hospital mortality in our primary analysis (adjusted odds ratio, 3.00; 95% confidence interval, 2.14–4.20; P<0.001) and in all sensitivity analyses.
Conclusions
Mechanical ventilation for the sole purpose of airway protection among patients with cirrhosis and grade IV hepatic encephalopathy may be associated with increased in-hospital mortality. Future studies are necessary to confirm and further characterize our findings.

Citations

Citations to this article as recorded by

Using machine learning methods to predict 28-day mortality in patients with hepatic encephalopathy
Zhe Zhang, Jian Wang, Wei Han, Li Zhao
BMC Gastroenterology.2023;[Epub] CrossRef

Infection
Ability of a modified Sequential Organ Failure Assessment score to predict mortality among sepsis patients in a resource-limited setting: Bodin Khwannimit, Rungsun Bhurayanontachai, Veerapong Vattanavanit; Acute Crit Care. 2022;37(3):363-371. Published online August 4, 2022; DOI: https://doi.org/10.4266/acc.2021.01627

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Abstract PDF Supplementary Material: Copyright © 2022 The Korean Society of Critical Care Medicine This is an Open Access article distributed under the terms of Creative Attributions Non- Commercial License (https://creativecommons. org/li-censes/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.accjournal.org 363 INTRODUCTION Sepsis is a life-threatening condition and constitutes major health care problems around the world [1,2]. Sepsis was associated with nearly 20% of all global deaths, and the majority of sepsis cases occurred in low- or middle-income countries [1]. In 2017, the World Health Organization recommended actions to reduce the global burden of sepsis [2]. Sepsis has been defined as acute life-threatening organ dysfunction due to dysregulation of host responses to Background: Some variables of the Sequential Organ Failure Assessment (SOFA) score are not routinely measured in sepsis patients, especially in countries with limited resources. Therefore, this study was conducted to evaluate the accuracy of the modified SOFA (mSOFA) and compared its ability to predict mortality in sepsis patients to that of the original SOFA score.
Methods
Sepsis patients admitted to the medical intensive care unit of Songklanagarind Hospital between 2011 and 2018 were retrospectively analyzed. The primary outcome was all-cause in-hospital mortality.
Results
A total of 1,522 sepsis patients were enrolled. The mean SOFA and mSOFA scores were 9.7±4.3 and 8.8±3.9, respectively. The discrimination of the mSOFA score was significantly higher than that of the SOFA score for all-cause in-hospital mortality (area under the receiver operating characteristic curve, 0.891 [95% confidence interval, 0.875–0.907] vs. 0.879 [0.862–0.896]; P<0.001), all-cause intensive care unit (ICU) mortality (0.880 [0.863–0.898] vs. 0.871 [0.853–0.889], P=0.01) and all-cause 28-day mortality (0.887 [0.871–0.904] vs. 0.874 [0.856–0.892], P<0.001). The ability of mSOFA score to predict all-cause in-hospital and 28-day mortality was higher than that of the SOFA score within the subgroups of sepsis according to age, sepsis severity and serum lactate levels. The mSOFA score was demonstrated to have a performance similar to the original SOFA score regarding the prediction of mortality in sepsis patients with cirrhosis or hepatic dysfunction.
Conclusions
The mSOFA score was a good alternative to the original SOFA core in predicting mortality among sepsis patients admitted to the ICU.

Pediatrics
Characteristics and prognostic factors of very elderly patients admitted to the intensive care unit: Song-I Lee, Younsuck Koh, Jin Won Huh, Sang-Bum Hong, Chae-Man Lim; Acute Crit Care. 2022;37(3):372-381. Published online August 4, 2022; DOI: https://doi.org/10.4266/acc.2022.00066

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Abstract PDF Supplementary Material

Background
Korea is rapidly becoming a super aging society and is facing the increased burden of critical care for the elderly people. Traditionally, far-advanced age has been regarded as a triage criterion for intensive care unit (ICU) admission. We evaluated how the characteristics and prognostic factors of very elderly patients (≥85 years) admitted to the ICU changed over the last decade.
Methods
We retrospectively evaluated the data of patients admitted to the ICU over 11 years (2007–2017). The clinical characteristics and outcomes of the very elderly-patients group were evaluated. Factors associated with mortality were assessed by a cox regression analysis.
Results
Comparing the first half (2007–2012) and the second half (2013–2017) of the study period, the proportion of very elderly group increased from 603/47,657 (1.3%), to 697/37,756 (1.8%) (P<0.001). Among 1,294 very elderly patients, 1,274 patients were analyzed excluding hopeless discharge (n=20). The non-surgical reasons for ICU admission (67.0% vs. 76.1%, P<0.001) and the percentage of patients with co-morbidities (78.3% vs. 82.7%, P=0.048) were increased. Nevertheless, the hospital mortality decreased (21.3% vs. 14.9%, P=0.001). High creatinine levels, use of vasopressors and ventilator weaning failure were associated with in-hospital mortality.
Conclusions
The proportion of very elderly people in the ICU increased over the last decade. The non-surgical causes of ICU admission increased compared with the surgical causes. Despite an increasement in ICU admissions of very elderly patients, in-hospital mortality of very elderly ICU patients decreased.

Citations

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We need a comprehensive intensive care unit management strategy for older patients
Dong-Ick Shin
Acute and Critical Care.2022; 37(3): 468. CrossRef

Nutrition
Effect of a nutritional support protocol on enteral nutrition and clinical outcomes of critically ill patients: a retrospective cohort study: Heemoon Park, Sung Yoon Lim, Sebin Kim, Hyung-Sook Kim, Soyeon Kim, Ho Il Yoon, Young-Jae Cho; Acute Crit Care. 2022;37(3):382-390. Published online July 19, 2022; DOI: https://doi.org/10.4266/acc.2022.00220

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Abstract PDF Supplementary Material

Background
Enteral nutrition (EN) supply within 48 hours after intensive care unit (ICU) admission improves clinical outcomes. The “new ICU evaluation & development of nutritional support protocol (NICE-NST)” was introduced in an ICU of tertiary academic hospital. This study showed that early EN through protocolized nutritional support would supply more nutrition to improve clinical outcomes.
Methods
This study screened 170 patients and 62 patients were finally enrolled; patients who were supplied nutrition without the protocol were classified as the control group (n=40), while those who were supplied according to the protocol were classified as the test group (n=22).
Results
In the test group, EN started significantly earlier (3.7±0.4 days vs. 2.4±0.5 days, P=0.010). EN calorie (4.0±1.0 kcal/kg vs. 6.7±0.9 kcal/kg, P=0.006) and protein (0.17±0.04 g/kg vs. 0.32±0.04 g/kg, P=0.002) supplied were significantly higher in the test group. Although EN was supplied through continuous feeding in the test group, there was no difference in complications such as feeding hold due to excessive gastric residual volume or vomit, and hyper- or hypo-glycemia between the two groups. Hospital mortality was significantly lower in the group that started EN within 1.5 days (42.9% vs. 11.8%, P=0.018). The proportion of patients who started EN within 1.5 days was higher in the test group (40.9% vs. 17.5%, P=0.044).
Conclusions
The NICE-NST may improve EN supply and mortality of critically ill patients without increasing complications.

Citations

Citations to this article as recorded by

Nutritional support for patients with abdominal surgical pathology: the view of a surgeon and an anesthesiologist — opponents or allies?
Natalya P. Shen, Svetlana Yu. Mukhacheva
Clinical nutrition and metabolism.2023; 3(4): 181. CrossRef
Provision of Enteral Nutrition in the Surgical Intensive Care Unit: A Multicenter Prospective Observational Study
Chan-Hee Park, Hak-Jae Lee, Suk-Kyung Hong, Yang-Hee Jun, Jeong-Woo Lee, Nak-Jun Choi, Kyu-Hyouck Kyoung
Annals of Clinical Nutrition and Metabolism.2022; 14(2): 66. CrossRef

Cardiology
The incidence of phlebitis development of high concentration of continuous amiodarone infusion with in-line filter compared to the low concentration without in-line filter: a retrospective propensity score-matched analysis: Sirichai Cheewatanakornkul, Piyanai Vattanaprasan, Supattra Uppanisakorn, Rungsun Bhurayanontachai; Acute Crit Care. 2022;37(3):391-397. Published online August 5, 2022; DOI: https://doi.org/10.4266/acc.2022.00080

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Abstract PDF: Background
Phlebitis-associated peripheral infusion of intravenous amiodarone is common in clinical practice, with an incidence between 5% and 65%. Several factors, including drug concentration, catheter size, and in-line filter used, are significantly associated with phlebitis occurrence. We performed a retrospective propensity score-matched analysis to find out whether in-line filter will reduce the incidence of amiodarone-induced phlebitis (AIP) in high concentration of amiodarone infusion compared to low concentration without in-line filter.
Methods
Clinical records of all patients who required intravenous amiodarone infusion for cardiac arrhythmias, between January 2017 to December 2019 were retrieved. The incidence of AIP was recorded and subsequently compared among high concentration (2 mg/ml) with an in-line filter and low concentration (1.5 mg/ml) infusion without an in-line filter after a 1 to 2 propensity score matched.
Results
The data indicated that among the 214 cases of amiodarone infusion collected, 28 cases used an in-line filter with high concentration while 186 cases received a low concentration of amiodarone infusion without an in-line filter. After 1:2 propensity score matching, the incidence of phlebitis in the high concentration with in-line filter group was significantly higher than the low concentration without in-line filter group (28.6% vs. 3.6%, P<0.01).
Conclusions
Despite the usage of in-line filter, the high concentration of amiodarone infusion resulted in a higher incidence of peripheral phlebitis. Central venous catheterization for a high concentration of amiodarone infusion is recommended.

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