This study was conducted to analyze the severe acute asthma admissions in Asir Central Hospital (ACH) in Abha, Saudi Arabia. In particular, it aimed to identify risk factors and final outcome of acute life-threatening asthma.
All patients admitted to the Intensive Care Unit (ICU) with acute bronchial asthma from June 1989 to May 1995 were analyzed. Total admis-sions to the ICU were obtained to determine the prevalence of asthma admission to the ICU.
There were 13 admissions for 8 patients. Three patients died and five were discharged in good condition. All patients received almost similar modes of therapy. Late presentation was the main cause of death. No patient died of asthma outside the ICU. Asthma constituted 0.42% of total ICU admissions. Several risk factors for admission to ICU were identified, including: poor compliance, previous requirement of systemic steroids, history of previous intubation, and psychiatric illness.
Asthma continued to be a cause of death despite the availability of treatment. Late presentation is the main cause of death. With proper management the outcome for a majority of patients could be good even in acute life-threatening asthma.
Acute; bronchial asthma; risk factors; life-threatening; Asir rsegion
Patients with chronic hepatitis C virus (HCV) can develop systemic cryoglobulinemic vasculitis. Combination of pegylated-interferon α and ribavirin is the first-line treatment of this condition. However, in case of severe or life-threatening manifestations, absence of a virological response, or autonomized vasculitis, immunotherapy (alone or in addition to the antiviral regimen) is necessary. Rituximab is to date the only biologic with a sufficient level of evidence to support its use in this indication. Several studies have demonstrated that rituximab is highly effective when cryoglobulinaemic vasculitis is refractory to antiviral regimen, that association of rituximab with antiviral regimen may induce a better and faster clinical remission, and, recently, that rituximab is more efficient than traditional immunosuppressive treatments. Some issues with regard to the optimal dose of rituximab or its use as maintenance treatment remain unsolved. Interestingly, in balance with this anti-inflammatory strategy, a recent pilot study reported the significant expansion of circulating regulatory T lymphocytes with concomitant clinical improvement in patients with refractory HCV-induced cryoglobulinaemic vasculitis using low dose of subcutaneous interleukin-2. This paper provides an updated overview on the place of immunotherapy, especially biologics, in the management of HCV-induced cryoglobulinaemic vasculitis.
Our objective was to describe self-sufficiency and quality of life one year after intensive care unit (ICU) discharge of patients aged 80 years or over.
We performed a prospective observational study in a medical-surgical ICU in a tertiary non-university hospital. We included patients aged 80 or over at ICU admission in 2005 or 2006 and we recorded age, admission diagnosis, intensity of care, and severity of acute and chronic illnesses, as well as ICU, hospital, and one-year mortality rates. Self-sufficiency (Katz Index of Activities of Daily Living) was assessed at ICU admission and one year after ICU discharge. Quality of life (WHO-QOL OLD and WHO-QOL BREF) was assessed one year after ICU discharge.
Of the 115 consecutive patients aged 80 or over (18.2% of admitted patients), 106 were included. Mean age was 84 ± 3 years (range, 80 to 92). Mortality was 40/106 (37%) at ICU discharge, 48/106 (45.2%) at hospital discharge, and 73/106 (68.9%) one year after ICU discharge. In the 23 patients evaluated after one year, self-sufficiency was unchanged compared to the pre-admission status. Quality of life evaluations after one year showed that physical health, sensory abilities, self-sufficiency, and social participation had slightly worse ratings than the other domains, whereas social relationships, environment, and fear of death and dying had the best ratings. Compared to an age- and sex-matched sample of the general population, our cohort had better ratings for psychological health, social relationships, and environment, less fear of death and dying, better expectations about past, present, and future activities and better intimacy (friendship and love).
Among patients aged 80 or over who were selected at ICU admission, 80% were self-sufficient for activities of daily living one year after ICU discharge, 31% were alive, with no change in self-sufficiency and with similar quality of life to that of the general population matched on age and sex. However, these results must be interpreted cautiously due to the small sample of survivors.
Systemic sclerosis (SSc) is a multiorgan connective tissue disease characterized by autoantibody production and fibroproliferative stenosis of the microvasculature. The vascoluopathy associated with SSc is considered to be noninflammatory, yet frank vasculitis can complicate SSc, posing diagnostic and therapeutic challenges. Here, we have reviewed the literature for reports of small-, medium-, and large-vessel vasculitis occurring in SSc. Amongst 88 reported cases of vasculitis in SSc, patients with ANCA-associated vasculitis appear to present a unique subclass in that they combined typical features of SSc with the renal manifestation of ANCA-associated glomerulonephritis. Other vasculitic syndromes, including large-vessel vasculitis, Behcet's disease, cryoglobulinemia, and polyarteritis nodosa, are rarely encountered in SSc patients. ANCA-associated vasculitis needs to be considered as a differential diagnosis in SSc patients presenting with renal insufficiency, as renal manifestations may result from distinct disease processes and require appropriate diagnostic testing and treatment.
The vasculitides encompass a rare subset of autoimmune diseases. Reports of the concurrent association of malignancies with some forms of vasculitis raise the possibility that patients with certain types of vasculitis may be at increased risk of cancer. Conversely, some forms of vasculitis may be a manifestation of malignancy. We review cancer risk in patients with large vessel vasculitis (giant cell arteritis and Takayasu arteritis), polyarteritis nodosa, and the circulating antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides. In addition we discuss vasculitis as a paraneoplastic phenomenon, highlighting polyarteritis nodosa in association with hairy cell leukemia and reviewing the most common vasculitic manifestation of cancer, cutaneous vasculitis.
cancer; cyclophosphamide; malignancy; paraneoplastic; vasculitis
The multiple organ dysfunction syndrome (MODS), though newly described, has manifested itself in intensive care unit (ICU) patients for several decades. As the name implies, it is a syndrome in which more than one organ system fails. Failure of these multiple organ systems may or may not be related to the initial injury or disease process for which the patient was admitted to the ICU. MODS is the leading cause of morbidity and mortality in current ICU practice. While the pathophysiology of MODS is not completely known, much evidence indicates that, during the initial injury which precipitates ICU admission, a chain of events is initiated which results in activation of several endogenous metabolic pathways. These pathways release compounds which, in and of themselves, are usually cytoprotective. However, an over exuberant activation of these endogenous systems results in an inflammatory response which can lead to development of failure in distant organs. As these organs fail, they activate and propagate the systemic inflammatory response. No therapy has proven entirely efficacious at modulating this inflammatory response and the incidence and severity of MODS. In current ICU practice, treatment is focused on prevention and treating individual organ dysfunction as it develops. With increased understanding of the pathophysiology of MODS therapy will come newer modalities which inhibit or interfere with the propagation of the endogenous systemic inflammatory response. These newer therapies hold great promise and already some are undergoing clinical investigation.
Consistent data about the incidence and outcome of sepsis in Latin American intensive care units (ICUs), including Brazil, are lacking. This study was designed to verify the actual incidence density and outcome of sepsis in Brazilian ICUs. We also assessed the association between the Consensus Conference criteria and outcome
This is a multicenter observational cohort study performed in five private and public, mixed ICUs from two different regions of Brazil. We prospectively followed 1383 adult patients consecutively admitted to those ICUs from May 2001 to January 2002, until their discharge, 28th day of stay, or death. For all patients we collected the following data at ICU admission: age, gender, hospital and ICU admission diagnosis, APACHE II score, and associated underlying diseases. During the following days, we looked for systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock criteria, as well as recording the sequential organ failure assessment score. Infection was diagnosed according to CDC criteria for nosocomial infection, and for community-acquired infection, clinical, radiological and microbiological parameters were used.
For the whole cohort, median age was 65.2 years (49–76), median length of stay was 2 days (1–6), and the overall 28-day mortality rate was 21.8%. Considering 1383 patients, the incidence density rates for sepsis, severe sepsis and septic shock were 61.4, 35.6 and 30.0 per 1000 patient-days, respectively. The mortality rate of patients with SIRS, sepsis, severe sepsis and septic shock increased progressively from 24.3% to 34.7%, 47.3% and 52.2%, respectively. For patients with SIRS without infection the mortality rate was 11.3%. The main source of infection was lung/respiratory tract.
Our preliminary data suggest that sepsis is a major public health problem in Brazilian ICUs, with an incidence density about 57 per 1000 patient-days. Moreover, there was a close association between ACCP/SCCM categories and mortality rate.
epidemiology; incidence; outcome; sepsis
Eosinopenia is a cheap and forgotten marker of acute infection that has not been evaluated previously in intensive care units (ICUs). The aim of the present study was to test the value of eosinopenia in the diagnosis of sepsis in patients admitted to ICUs.
A prospective study of consecutive adult patients admitted to a 12-bed medical ICU was performed. Eosinophils were measured at ICU admission. Two intensivists blinded to the eosinophils classified patients as negative or with systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, or septic shock.
A total of 177 patients were enrolled. In discriminating noninfected (negative + SIRS) and infected (sepsis + severe sepsis + septic shock) groups, the area under the receiver operating characteristic curve was 0.89 (95% confidence interval (CI), 0.83 to 0.94). Eosinophils at <50 cells/mm3 yielded a sensitivity of 80% (95% CI, 71% to 86%), a specificity of 91% (95% CI, 79% to 96%), a positive likelihood ratio of 9.12 (95% CI, 3.9 to 21), and a negative likelihood ratio of 0.21(95% CI, 0.15 to 0.31). In discriminating SIRS and infected groups, the area under the receiver operating characteristic curve was 0.84 (95% CI, 0.74 to 0.94). Eosinophils at <40 cells/mm3 yielded a sensitivity of 80% (95% CI, 71% to 86%), a specificity of 80% (95% CI, 55% to 93%), a positive likelihood ratio of 4 (95% CI, 1.65 to 9.65), and a negative likelihood ratio of 0.25 (95% CI, 0.17 to 0.36).
Eosinopenia is a good diagnostic marker in distinguishing between noninfection and infection, but is a moderate marker in discriminating between SIRS and infection in newly admitted critically ill patients. Eosinopenia may become a helpful clinical tool in ICU practices.
The incidence of fungal healthcare-associated infection (HAI) has increased in a major teaching hospital in the northern part of Taiwan over the past decade, especially in the intensive care units (ICUs). The purpose of this study was to determine the factors that were responsible for the outbreak and trend in the ICU.
Surveillance fungal cultures were obtained from “sterile” objects, antiseptic solutions, environment of infected patients and hands of medical personnel. Risk factors for comparison included age, gender, admission service, and total length of stay in the ICU, Acute Physiology and Chronic Health Evaluation (APACHE) II scores at admission to the ICU, main diagnosis on ICU admission, use of invasive devices, receipt of hemodialysis, total parenteral nutrition (TPN) use, history of antibiotic therapy before HAI or during ICU stay in no HAI group, and ICU discharge status (ie, dead or alive). Univariable analysis followed by multiple logistic regression analysis was performed to identify the independent risk factors for ICU fungal HAIs and ICU mortality.
There was a significant trend in ICU fungal HAIs from 1998 to 2009 (P < 0.001). A total of 516 episodes of ICU fungal HAIs were identified; the rates of various infections were urinary tract infection (UTI) (54.8%), blood stream infection (BSI) (30.6%), surgical site infection (SSI) (6.6%), pneumonia (4.5%), other sites (3.5%). The fungi identified were: yeasts (54.8%), Candida albicans (27.3%), Candida tropicalis (6.6%), Candida glabrata (6.6%), Candida parapsilosis (1.9%), Candida species (0.8%), and other fungi (1.9%). Candida albicans accounted for 63% of all Candida species. Yeasts were found in the environment of more heavily infected patients. The independent risk factors (P < 0.05) of developing ICU fungal HAIs from all sites were TPN use, sepsis, surgical patients, mechanical ventilation and an indwelling urinary catheter. The independent risk factors for ICU fungal UTI included TPN use, mechanical ventilation and an indwelling urinary catheter. The independent risk factors for ICU fungal BSI included TPN use, sepsis, and higher APACHE II score. The independent risk factors for ICU fungal pneumonia included TPN use, surgical patients. The independent risk factors for ICU fungal SSI included surgical patients, and TPN use. The odds ratios of TPN use in various infection types ranged from 3.51 to 8.82. The risk of mortality in patients with ICU fungal HAIs was over 2 times that of patients without ICU HAIs in the multiple logistic regression analysis (P < 0.001).
There was a secular trend of an increasing number of fungal HAIs in our ICU over the past decade. Patients with ICU fungal HAIs had a significantly higher mortality rate than did patients without ICU HAIs. Total parenteral nutrition was a significant risk factor for all types of ICU fungal HAIs, and its use should be monitored closely.
Intensive care unit; Fungal infection; Outbreak surveillance; Candida; Total parenteral nutrition
Diffused endothelial dysfunction in sepsis leads to an increase in systemic capillary permeability, the renal component manifesting as microalbuminuria. The degree of microalbuminuria correlates with the severity of the acute insult, the quantification of which may serve to predict sepsis and mortality in critically ill patients.
To evaluate whether the degree of microalbuminuria could differentiate patients with sepsis from those without and predict mortality in critically ill patients.
Settings and Design:
Prospective, non-interventional study in a 20-bed Intensive Care Unit (ICU) of a tertiary care hospital.
Methods and Materials:
After exclusions, between Jan-May 2007, 94 consecutive adult patients were found eligible. Albumin-creatinine ratio (ACR, mg/g) was measured in urine samples collected on ICU admission (ACR1) and at 24 hours (ACR2).
Patients were classified into two groups: those with sepsis, severe sepsis and septic shock (n = 30) and those without sepsis [patients without systemic inflammatory response syndrome (SIRS) and with SIRS due to noninfectious causes] (n = 64). In the sepsis group, median ACR1 [206.5 (IQR129.7-506.1)] was significantly higher compared to the non sepsis group [76.4 (IQR29-167.1)] (P = 0.0016, Mann Whitney). The receiver operating characteristics (ROC) curve analysis showed that at a cut off value 124 mg/g, ACR1 may be able to discriminate between patients with and without sepsis with a sensitivity of 80%, specificity of 64.1%, positive predictive value (PPV) of 51.1% and negative predictive value (NPV) of 87.3%. The median ACR2 [154 (IQR114.4-395.3)] was significantly higher (P = 0.004) in nonsurvivors (n = 13) as compared to survivors [50.8 (IQR 21.6-144.7)]. The ROC curve analysis revealed that ACR2 at a cut-off of 99.6 mg/g could predict ICU mortality with sensitivity of 85%, specificity of 68% with a NPV of 97% and PPV of 30%.
Absence of significant microalbuminuria on ICU admission is unlikely to be associated with sepsis. At 24 hours, absence of elevated levels of microalbuminuria is strongly predictive of ICU survival, equivalent to the time-tested APACHE II scores.
Capillary permeability; critically ill; intensive care units; microalbuminuria; sepsis; mortality
Computerized physician order entry (CPOE) systems are recommended to improve patient safety and outcomes. However, their effectiveness has been questioned. Our objective was to evaluate the impact of CPOE implementation on the outcome of critically ill patients.
This was an observational before-after study carried out in a 21-bed medical and surgical intensive care unit (ICU) of a tertiary care center. It included all patients admitted to the ICU in the 24 months pre- and 12 months post-CPOE (Misys®) implementation. Data were extracted from a prospectively collected ICU database and included: demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, admission diagnosis and comorbid conditions. Outcomes compared in different pre- and post-CPOE periods included: ICU and hospital mortality, duration of mechanical ventilation, and ICU and hospital length of stay. These outcomes were also compared in selected high risk subgroups of patients (age 12-17 years, traumatic brain injury, admission diagnosis of sepsis and admission APACHE II > 23). Multivariate analysis was used to adjust for imbalances in baseline characteristics and selected clinically relevant variables.
There were 1638 and 898 patients admitted to the ICU in the specified pre- and post-CPOE periods, respectively (age = 52 ± 22 vs. 52 ± 21 years, p = 0.74; APACHE II = 24 ± 9 vs. 24 ± 10, p = 0.83). During these periods, there were no differences in ICU (adjusted odds ratio (aOR) 0.98, 95% confidence interval [CI] 0.7-1.3) and in hospital mortality (aOR 1.00, 95% CI 0.8-1.3). CPOE implementation was associated with similar duration of mechanical ventilation and of stay in the ICU and hospital. There was no increased mortality or stay in the high risk subgroups after CPOE implementation.
The implementation of CPOE in an adult medical surgical ICU resulted in no improvement in patient outcomes in the immediate phase and up to 12 months after implementation.
Intensive care unit; critical illness; CPOE; safety management; mortality; morbidity
The manifestations of human immunodeficiency virus (HIV) infection are protean and vasculitides are one of the less common but nonetheless important consequences. A wide range of vasculitides can be encountered, ranging from vasculitis resulting from specific infective agents to a non-specific vasculitis. Among the infective causes, cytomegalovirus and tuberculosis are probably the most common. A polyarteritis nodosa-like vasculitis with important differences to classic polyarteritis nodosa is also described. Hypersensitivity vasculitis resulting in several patterns of vasculitis and angiocentric immunoproliferative vasculitis are well recognised. As part of the immunocompromise caused by HIV, a granulomatous inflammation involving small arteries and veins of the brain surface and leptomeninges, termed a primary angiitis of the central nervous system, is a rare vasculitis associated with high mortality. A recently described large vessel (aorta, femorals, carotids) vasculopathy resulting in either multiple aneurysm formation or occlusive disease is seen in young adults. An infective agent is not found but aetiologically some of these lesions might be the result of a leucocytoclastic vasculitis of vasa vasora or periadventitial vessels. A final group of non-specific vasculitides not fitting into any of the characteristic patterns described accounts for the residue of vasculitides associated with HIV.
Key Words: human immunodeficiency virus • vasculitis • immunocompromise
To evaluate if severity of illness in the intensive care unit influences patients' retrospective recall of their baseline physical function from prior to hospital admission.
Materials and Methods
A prospective cohort study of 193 acute lung injury (ALI) survivors who, prior to hospital discharge, retrospectively reported their pre-hospitalization physical function using the SF-36 quality of life survey.
Four measures were used to evaluate ICU severity of illness: (1) Acute Physiology and Chronic Health Evaluation II Acute Physiologic Score at ICU admission, (2) Lung Injury Score at ALI diagnosis, (3) Sequential Organ Failure Assessment (SOFA) score at study enrollment, and (4) maximum daily SOFA score during the entire ICU stay. In multivariable linear regression analysis, no measure of severity of illness was associated with prehospitalization Physical Function. Education level significantly modified the relationship between ICU severity of illness and baseline Physical Function with lower educational attainment having a stronger association with baseline physical function.
ICU severity of illness was not associated with patients' retrospectively recalled baseline physical function. Patients with a lower level of education maybe more influenced by ICU severity of illness, but the magnitude of this effect may not be clinically meaningful.
Critical care; Quality of life; Respiratory distress syndrome, adult; Health status; Mental recall; Bias, epidemiologic
To describe the epidemiologic characteristics, clinical features, and outcome of severe cases of 2009 H1N1 influenza A infections who were admitted to the intensive care units (ICUs) in Damascus, Syria.
Materials and Methods:
Retrospectively, we collected clinical data on all patients who were admitted to the ICU with confirmed or suspected diagnosis of severe 2009 H1N1 influenza A with respiratory failure at 4 major tertiary care hospitals in Damascus, Syria. Acute Physiology and Chronic Health Evaluation (APACHE) II system was used to assess the severity of illness within the first 24 h after admission. The outcome was overall hospital mortality.
Eighty patients were admitted to the ICU with severe 2009 H1N1 infection. The mean age was 40.7 years; 69.8% of patients had ≥1 of the risk factors: asthmatics 20%, obesity 23.8%, and pregnancy 5%; and 72.5% had acute lung injury or adult respiratory distress syndrome, 12.5% had viral pneumonia, 42.5% had secondary bacterial pneumonia, and 15% had exacerbation of airflow disease. Mechanical ventilation was required in 73.7% of cases. The mean hospital length of stay was 11.7 days (median 8 days, range 0–77 days, IQR: 5–14 days). The overall mortality rate was 51% for a mean APACHE II score of 15.2 with a predicted mortality of 21% (standardized mortality ratio of 2.4, 95% confidence interval: 1.7–3.2, P value < 0.001).
Critically ill patients with severe 2009 H1N1 infection in this limited resource country had a much higher mortality rate than the predicted APACHE II mortality rate or when compared with the reported mortality rates for severe cases in other countries during 2009 H1N1 pandemic.
Adult respiratory distress syndrome; H1N1; pandemic; Syria
When the number of patients who require intensive care is greater than the number of beds available, intensive care unit (ICU) entry flow is obstructed. This phenomenon has been associated with higher mortality rates in patients that are not admitted despite their need, and in patients that are admitted but are waiting for a bed. The purpose of this study is to evaluate if a delay in ICU admission affects mortality for critically ill patients.
A prospective cohort of adult patients admitted to the ICU of our institution between January and December 2005 were analyzed. Patients for whom a bed was available were immediately admitted; when no bed was available, patients waited for ICU admission. ICU admission was classified as either delayed or immediate. Confounding variables examined were: age, sex, originating hospital ward, ICU diagnosis, co-morbidity, Acute Physiology and Chronic Health Evaluation (APACHE) II score, therapeutic intervention, and Sequential Organ Failure Assessment (SOFA) score. All patients were followed until hospital discharge.
A total of 401 patients were evaluated; 125 (31.2%) patients were immediately admitted and 276 (68.8%) patients had delayed admission. There was a significant increase in ICU mortality rates with a delay in ICU admission (P = 0.002). The fraction of mortality risk attributable to ICU delay was 30% (95% confidence interval (CI): 11.2% to 44.8%). Each hour of waiting was independently associated with a 1.5% increased risk of ICU death (hazard ratio (HR): 1.015; 95% CI 1.006 to 1.023; P = 0.001).
There is a significant association between time to admission and survival rates. Early admission to the ICU is more likely to produce positive outcomes.
To examine whether nosocomial infection risk increases with APACHE II score, which is an index of severity-of-illness, in intensive care unit (ICU) patients.
Using the Japanese Nosocomial Infection Surveillance database, 8,587 patients admitted to 34 participating ICUs between July 2000 and May 2002, aged 16 years or older, who had stayed in the ICU for 2 days or longer, had not transferred to another ICU, and had not been infected within 2 days after ICU admission, were followed until ICU discharge, Day 14 after ICU admission, or the development of nosocomial infection. Adjusted odds ratios with their 95% confidence intervals for nosocomial infections were calculated using logistic regression models, which incorporated sex, age, operation, ventilator; central venous catheter, and APACHE II score (0–5, 6–10, 11–15, 16–20, 21–25, 26–30, and 31+).
There were 683 patients with nosocomial infections. Adjusted odds ratios for nosocomial infections gradually increased with APACHE II score. Women and elective operation showed significantly low odds ratios, while urgent operation, ventilator, and central venous catheter showed significantly high odds ratios. Age had no significant effect on the development of nosocomial infection.
Nosocomial infection risk increases with APACHE II score. APACHE II score may be a good predictor of nosocomial infections in ICU patients.
multicenter cohort study; ICU; APACHE II score; nosocomial infection
Risk adjustment systems now in use were developed more than a decade ago and lack prognostic performance. Objective of the SAPS 3 study was to collect data about risk factors and outcomes in a heterogeneous cohort of intensive care unit (ICU) patients, in order to develop a new, improved model for risk adjustment.
Prospective multicentre, multinational cohort study.
Patients and setting
A total of 19,577 patients consecutively admitted to 307 ICUs from 14 October to 15 December 2002.
Measurements and results
Data were collected at ICU admission, on days 1, 2 and 3, and the last day of the ICU stay. Data included sociodemographics, chronic conditions, diagnostic information, physiological derangement at ICU admission, number and severity of organ dysfunctions, length of ICU and hospital stay, and vital status at ICU and hospital discharge. Data reliability was tested with use of kappa statistics and intraclass-correlation coefficients, which were >0.85 for the majority of variables. Completeness of the data was also satisfactory, with 1 [0–3] SAPS II parameter missing per patient. Prognostic performance of the SAPS II was poor, with significant differences between observed and expected mortality rates for the overall cohort and four (of seven) defined regions, and poor calibration for most tested subgroups.
The SAPS 3 study was able to provide a high-quality multinational database, reflecting heterogeneity of current ICU case-mix and typology. The poor performance of SAPS II in this cohort underscores the need for development of a new risk adjustment system for critically ill patients.
Electronic Supplementary Material
Electronic supplementary material is included in the online fulltext version of this article and accessible for authorised users: http://dx.doi.org/10.1007/s00134-005-2762-6
Intensive care unit; Severity of illness; ICU mortality; Hospital mortality; Risk adjustment
Interleukin (IL)-17 (also known as IL-17A) is produced by activated T cells. It is a marker cytokine of the TH17 lineage. IL-17 production is induced in infections, autoimmune diseases and other inflammatory events. IL-17 is involved in host defense, but also inflammatory tissue destruction. Vascular disease, mostly in the chronic form of atherosclerosis, is a leading cause of death. While normal vessels harbor only few leukocytes, large numbers of both innate and adaptive immune cells accumulate during vascular inflammation, both in chronic forms such as atherosclerosis and in acute vasculitis. IL-17 has a role in chronic vascular inflammation of atherosclerosis and possibly hypertensive vascular changes. In acute inflammation, IL-17 is elevated and may be causally involved in the autoimmune vasculitides including vasculitis in systemic lupus erythematodes. Blood vessels are important targets in alloimmune graft rejection and a number of studies provide data on a role of IL-17 in this context. This brief review summarizes the currently available evidence for and putative mechanisms of action of IL-17 in mouse models of and human vascular disease.
Interleukin 17; T cells; atherosclerosis; vasculitis; vasculopathy
Patients with end-stage renal disease (ESRD) experience higher rates of hospitalisation, cardiovascular events, and all-cause mortality and are more likely to require admission to the intensive care unit (ICU) than patients with normal renal function. Sepsis and cardiovascular diseases are the most common reasons for ICU admission. ICU mortality rates in patients requiring chronic hemodialysis are significantly higher than for patients without ESRD; however, dialysis patients have a better ICU outcome than those with acute kidney injury (AKI) requiring renal replacement therapy suggesting that factors other than loss of renal function contribute to their prognosis. Current evidence suggests, the longer-term outcomes after discharge from ICU may be favourable and that long-term dependence on dialysis should not prejudice against prompt referral or admission to ICU.
Objectives: To investigate the causes, course, and outcome of critical illness requiring emergency admission to the intensive care unit (ICU) in patients with systemic lupus erythematosus (SLE) or the antiphospholipid syndrome (APS), or both.
Methods: Critically ill patients with SLE or APS, or both, admitted to a London teaching hospital ICU over a 15 year period were studied. Demographic, diagnostic, physiological, laboratory, and survival data were analysed. Kaplan-Meier survival curves were constructed by age, time from first diagnosis of SLE, and time from first ICU admission. The log rank test and a backwards stepwise Cox regression were used to identify factors associated with reduced survival.
Results: Sixty one patients with SLE alone (39%) and/or APS (61%) required 76 emergency admissions to the ICU. Patients had high severity of illness scores (median APACHE II 22 (range 8–45)) and multiorgan dysfunction. The primary diagnoses for patients admitted were infection in 31/76 (41%), renal disease in 16/76 (21%), cardiovascular disease in 12/76 (16%), and coagulopathies in 11/76 (14%). The commonest secondary diagnosis was renal dysfunction (49%). Factors associated with an increased risk of death were cyclophosphamide before admission, low white cell count, and high severity of illness score. Before adjustment for these factors renal disease had a strong adverse effect on long term survival (analysis by age at diagnosis p=0.005, analysis by time since first ICU admission, p=0.07). After adjustment, infection at admission to ICU was associated with an increased ICU mortality (p=0.02) and was the cause of death in 13/17 patients who died in the ICU. Similarly, after adjustment, APS was associated with reduced ICU survival (p=0.1) and reduced long term (p=0.03) survival. Seventeen patients (28%) died in the ICU, and 31 patients (51%) had died by the last follow up. Median time from ICU admission to death was four years. Overall five year survival from the first ICU admission was 43%.
Conclusion: Critical illness requiring ICU admission may occur in patients with SLE and APS. In this study, ICU survival was better than previously described, but long term survival was poor. Cyclophosphamide administration, low white cell count, and high severity of illness score were associated with reduced survival. Before adjustment for these factors, only renal disease had an adverse effect on outcome but after adjustment, infection and APS reduced survival.
This report describes the case mix, outcome and activity (duration of intensive care unit [ICU] and hospital stay, inter-hospital transfer, and readmissions to the ICU) for admissions to ICUs for acute severe asthma, and investigates the effect of case mix factors on outcome.
We conducted a secondary analysis of data from a high-quality clinical database (the Intensive Care National Audit and Research Centre [ICNARC] Case Mix Programme Database) of 129,647 admissions to 128 adult, general critical care units across England, Wales and Northern Ireland over the period 1995–2001.
Asthma accounted for 2152 (1.7%) admissions, and in 57% mechanical ventilation was employed during the first 24 hours in the ICU. A total of 147 (7.1%) patients died in intensive care and 199 (9.8%) died before discharge from hospital. The mean age was 43.6 years, and the ratio of women to men was 2:1. Median length of stay was 1.5 days in the ICU and 8 days in hospital. Older age, female sex, having received cardiopulmonary resuscitation (CPR) within 24 hours before admission, having suffered a neurological insult during the first 24 hours in the ICU, higher heart rate, and hypercapnia were associated with greater risk for in-hospital death after adjusting for Acute Physiology and Chronic Health Evaluation II score. CPR before admission, neurological insult, hypoxaemia and hypercapnia were associated with receipt of mechanical ventilation after adjusting for Acute Physiology and Chronic Health Evaluation II score.
ICU admission for asthma is relatively uncommon but remains associated with appreciable in-hospital mortality. The greatest determinant of poor hospital survival in asthma patients was receipt of CPR within 24 hours before admission to ICU. Clinical management of these patients should be directed at preventing cardiac arrest before admission.
asthma; critical care; intensive care units; mechanical ventilation; mortality
Background. The systemic vasculitides are syndromes characterized by inflammation and injury (necrosis or thrombosis) of blood vessels, resulting in clinical manifestations according to the affected vascular bed, but not classically in stocking-glove neuropathy. Objective. To describe a form of primary vasculitis affecting strictly peripheral nerves manifesting as stocking-glove neuropathy. Methods. Case series of 110 patients seen in three centers in Bogotá who presented with symptoms and signs of polyneuropathy and/or were identified with vasculitis affecting only the peripheral nerves, and who underwent sural nerve biopsy. Results. Six patients had a vasculitis affecting only the peripheral nerves diagnosed on sural nerve biopsy which demonstrated a mixed infiltrate of monocytes/macrophages and lymphocytes especially in the small epineurial blood vessels. Over time, all had worsening of symptoms, with grip weakness and motor deficits in the hand and feet. Serologies and acute phase reactants were normal in all patients. Treatment response to immunosuppression was satisfactory in 5 patients; 1 patient had progressive neurologic damage. Conclusions. There is a distinct form of primary vasculitis of the peripheral nervous system characterized by distal sensory polyneuropathy with stocking-glove distribution with good prognosis, few and minor relapses and good response to treatment even after delayed diagnosis.
To assess intensive care unit (ICU)/acute care service-delivery characteristics and pre-ICU factors as predictors of posttraumatic stress disorder (PTSD) and return to usual major activity after ICU admission for trauma.
Data from the National Study on the Costs and Outcomes of Trauma was used to evaluate a prospective cohort of 1,906 ICU survivors. We assessed PTSD with the PTSD Checklist. Regression analyses ascertained associations between ICU/acute care service-delivery characteristics, pre-ICU factors, early post-ICU distress, and 12-month PTSD and return to usual activity, while controlling for clinical and demographic characteristics.
Approximately 25% of ICU survivors had symptoms suggestive of PTSD. Increased early post-ICU distress predicted both PTSD and diminished usual major activity. Pulmonary artery catheter insertion (Risk Ratio (RR) 1.28, 95% Confidence Interval (95%CI) (1.05-1.57), p=0.01) and pre-ICU depression (RR 1.23, 95%CI (1.02-1.49), p=0.03) were associated with PTSD. Longer ICU lengths of stay (RR 1.21, 95%CI (1.03-1.44), p=0.02) and tracheostomy (RR 1.29, 95%CI (1.05-1.59), p=0.01) were associated with diminished usual activity. Greater pre-existing medical co-morbidities were associated with PTSD and limited return to usual activity.
Easily identifiable risk factors including ICU/acute care service-delivery characteristics and early post-ICU distress were associated with increased risk of PTSD and limitations in return to usual major activity. Future investigations could develop early screening interventions in acute care settings targeting these risk factors, facilitating appropriate treatments.
stress disorder; posttraumatic; critical care; intensive care unit; risk factors; outcome assessment (health care)
Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome.
Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score.
Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t-test. Primary outcome measure was ICU mortality.
Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P=0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality (P=0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6–100).
Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics.
Blood stream infection; ICU admission bacteremia; multiorgan dysfunction; risk factors for bacteremia
Background: Previous studies have shown that the outcome of lung cancer patients who were admitted to the Intensive Care Unit (ICU), especially those requiring mechanical ventilation, is extremely poor. The present study was conducted in order to assess the outcome of a recent cohort of lung cancer patients admitted to the ICU with acute respiratory failure.
Methods: A retrospective analysis of the medical records of 105 lung cancer patients who were admitted to the ICU between January 2008 and January 2011 was performed. Severity of illness on the first day of ICU admission was assessed using the acute physiology and chronic health evaluation (APACHE) II and the sequential organ failure assessment (SOFA) scoring systems. Associated organ failure was determined according to the Knaus criteria.
Results: Eighty four (80%) patients were diagnosed with non-small cell lung cancer, 14 (13.3%) with small cell lung cancer, one patient with mesothelioma, and in the remaining 6 patients, the type of lung cancer could not be determined. Significant factors on admission were APACHE II and SOFA scores, poor performance status and severe comorbidity. During ICU stay, the main risk factors for poor outcome were the long term mechanical ventilation duration, use of vasopressors, more than two organ system failures and septic condition. The overall ICU, hospital and 6-month mortality rates were 44.7% (47/105), 56.1% (59/105) and 77.1% (81/105) respectively.
Conclusions: The present data show that the medical intensive care unit outcome of lung cancer patients is improving. Further studies of patients selected to ICU admission are needed to assess long-term mortality, quality of life, ability to continue chemotherapy and economic cost.
Lung cancer; intensive care unit; respiratory failure