Admission sodium levels and hospital outcomes

The clinical complication scale of Fondazione Don Gnocchi for classifying clinical complications in patients with severe acquired brain injury: development and multicenter validation

Introduction

Patients with severe acquired brain injury have a high risk of developing clinical complications that affect clinical outcome and rehabilitation program. Early identification of clinical complications would allow to treat them appropriately and to prevent their worsening. However, available clinical scales for recording clinical complications are not appropriately tailored for this population. The present multicenter study aimed at developing and validating a new scale to categorize the clinical complications: the Clinical Complication Scale of the Fondazione Don Gnocchi (FDG-CCS).

Methods

Six Intensive Neurorehabilitation Units enrolled consecutively admitted patients with severe brain injury. Demographic, anamnestic, and clinical data were collected at study entry. For each enrolled patient, two independent examiners (A and B) administered the FDG-CCS considering 2 weeks as an observation time window. Concurrently, a third examiner (C) administered the Comorbidities Coma Scale. The blinded examinations were analyzed to assess the inter-rater agreement (A vs. B) and the concurrent validity of the FDG-CCS with respect to the Comorbidities Coma Scale (C).

Results

A total of 42 patients (22 patients with and 20 emerged from prolonged disorder of consciousness) were enrolled. The FDG-CCS total score did not differ in the two subgroups of patients. Metabolic (examiner A = 33%; examiner B = 43%), gastro-intestinal (A = 31%; B = 26%), cardio-vascular (A = 26%; B = 29%), respiratory (A = 21%; B = 21%), and musculo-skeletal disorders (A = 19%; B = 14%) were the most frequent complications. Inter-rater agreement for the total score of the FDG-CCS resulted to be good (intra-class correlation coefficient = 0.865; p < 0.05), and the FDG-CCS total score correlated significantly with the total score of the Comorbidities Coma Scale (A, ρ = 0.356; p = 0.01; B, ρ = 0.317; p = 0.02).

Discussion

The present multicenter study proposed and validated a novel clinical tool for the categorization of clinical complications of patients with severe brain injury. This clinical tool could help the rehabilitation team for planning tailored treatment and prevention of clinical complications that negatively impact patients' outcomes and hamper rehabilitation programs.

Explainable machine learning for predicting neurological outcome in hemorrhagic and ischemic stroke patients in critical care

Aim

The objective of this study is to develop accurate machine learning (ML) models for predicting the neurological status at hospital discharge of critically ill patients with hemorrhagic and ischemic stroke and identify the risk factors associated with the neurological outcome of stroke, thereby providing healthcare professionals with enhanced clinical decision-making guidance.

Materials and methods

Data of stroke patients were extracted from the eICU Collaborative Research Database (eICU-CRD) for training and testing sets and the Medical Information Mart for Intensive Care IV (MIMIC IV) database for external validation. Four machine learning models, namely gradient boosting classifier (GBC), logistic regression (LR), multi-layer perceptron (MLP), and random forest (RF), were used for prediction of neurological outcome. Furthermore, shapley additive explanations (SHAP) algorithm was applied to explain models visually.

Results

A total of 1,216 hemorrhagic stroke patients and 954 ischemic stroke patients from eICU-CRD and 921 hemorrhagic stroke patients 902 ischemic stroke patients from MIMIC IV were included in this study. In the hemorrhagic stroke cohort, the LR model achieved the highest area under curve (AUC) of 0.887 in the test cohort, while in the ischemic stroke cohort, the RF model demonstrated the best performance with an AUC of 0.867 in the test cohort. Further analysis of risk factors was conducted using SHAP analysis and the results of this study were converted into an online prediction tool.

Conclusion

ML models are reliable tools for predicting hemorrhagic and ischemic stroke neurological outcome and have the potential to improve critical care of stroke patients. The summarized risk factors obtained from SHAP enable a more nuanced understanding of the reasoning behind prediction outcomes and the optimization of the treatment strategy.

Systemic and iatrogenic factors contribute to the development of severe hypernatraemia in vulnerable inpatients

OBJECTIVES

To determine all-cause in-hospital mortality associated with severe hypernatraemia and the causes, comorbidities, time to treatment, discharge destination and postdischarge mortality.

DESIGN

Retrospective observational cohort study.

PATIENTS

Severe hypernatraemia, (sodium concentration ≥ 155 mmol/L), at any time during a tertiary hospital admission in Melbourne, Australia, 1 January 2019 to 31 December 2019 (pre-COVID19).

MEASUREMENTS

Deaths, Charlson Comorbidity Index (CCI), hypernatraemia causes, time to treatment, discharge destination.

RESULTS

One hundred and one inpatients: 64 community-acquired, 37 hospital-acquired. In-hospital mortality was 38%, but cumulative mortality was 65% by 1 month after discharge, with only a minor further increase at 6 and 12 months. After adjusting for peak sodium concentration, the community acquired group had significantly reduced odds of in-hospital mortality (odds ratio 0.15, 95% confidence interval [0.04-0.54], p = .003). Iatrogenic factors were present in 57% (21/37) of the hospital-acquired group. Only 55% of all cases received active sodium directed treatment. Time to start treatment did not affect outcomes. High levels of comorbidity were present, median CCI (IQR) was 6 (5-8) in the community and 5 (4-7) in the hospital group. Dementia prevalence was higher in the community group, 66% (42/64) versus 19% (7/37) (p = .001). Infection was the most common precipitant with 52% (33/64) in the community and 32% (12/37) in the hospital group. Of the survivors, 32% who had been living independently required residential care after discharge.

CONCLUSIONS

Mortality was high and loss of independence in survivors common. To potentially improve outcomes, hypernatraemia-specific guidelines should be formulated and efforts made to reduce system and iatrogenic factors.

Dysnatremia is associated with increased risk of all-cause mortality within 365 days post-discharge in patients with atrial fibrillation without heart failure: A prospective cohort study

AIM

The aim of this study is to evaluate the association between serum sodium concentrations at hospital admission and all-cause mortality within 365 days post-discharge in patients with atrial fibrillation (AF) without heart failure (HF).

METHODS

The prospective cohort study enrolled 1,446 patients with AF without HF between November 2018 and October 2020. A follow-up was performed 30, 90, 180, and 365 days after enrollment through outpatient visits or telephone interviews. All-cause mortality was estimated in three groups according to serum sodium concentrations: hyponatremia (< 135 mmol/L), normonatremia (135-145 mmol/L), and hypernatremia (> 145 mmol/L). We estimated the risk of all-cause mortalities using univariable and multivariable Cox proportional hazards models with normonatremia as the reference.

RESULTS

The all-cause mortalities of hyponatremia, normonatremia, and hypernatremia were 20.6, 9.4, and 33.3% within 365 days post-discharge, respectively. In the univariable analysis, hyponatremia (HR: 2.19, CI 1.5-3.2) and hypernatremia (HR: 4.03, CI 2.32-7.02) increased the risk of all-cause mortality. The HRs for hyponatremia and hypernatremia were 1.55 (CI 1.05-2.28) and 2.55 (CI 1.45-4.46) after adjustment for age, diabetes mellitus, loop diuretics, antisterone, antiplatelet drugs, and anticoagulants in the patients with AF without HF. The association between serum sodium concentrations and the HRs of all-cause mortality was U-shaped.

CONCLUSION

Dysnatremia at hospital admission was an independent factor for all-cause mortality in patients with AF without HF within 365 days post-discharge.

Association of Hypernatremia with Immune Profiles and Clinical Outcomes in Adult Intensive Care Unit Patients with Sepsis

Both hypernatremia and an abnormal immune response may increase hospital mortality in patients with sepsis. This study examined the association of hypernatremia with abnormal immune response and mortality in 520 adult patients with sepsis in an intensive care unit (ICU). We compared the mortality and ex vivo lipopolysaccharide (LPS)-induced inflammatory response differences among patients with hyponatremia, eunatremia, and hypernatremia, as well as between patients with acquired hypernatremia on ICU day 3 and those with sustained eunatremia over first three ICU days. Compared with eunatremia or hyponatremia, hypernatremia led to higher 7 day, 14 day, 28 day, and hospital mortality rates (p = 0.030, 0.009, 0.010, and 0.033, respectively). Compared with sustained eunatremia, acquired hypernatremia led to higher 7, 14, and 28 day mortality rates (p = 0.019, 0.042, and 0.028, respectively). The acquired hypernatremia group nonsignificantly trended toward increased hospital mortality (p = 0.056). Day 1 granulocyte colony-stimulating factor (G-CSF) and tumor necrosis factor (TNF) α levels were relatively low in patients with hypernatremia (p = 0.020 and 0.010, respectively) but relatively high in patients with acquired hypernatremia (p = 0.049 and 0.009, respectively). Thus, in ICU-admitted septic patients, hypernatremia on admission and in ICU-acquired hypernatremia were both associated with higher mortality. The higher mortality in patients with hypernatremia on admission was possibly related to the downregulation of G-CSF and TNF-α secretion after endotoxin stimulation. Compared to sustained eunatremia, acquired hypernatremia showed immunoparalysis at first and then hyperinflammation on day 3.

Prognostic importance of deranged sodium level in critically ill patients: A systemic literature to review

It is common upon admission or during stay at a hospital or intensive care unit (ICU) for patients to present with or acquire a serum sodium abnormality. Hyponatremia, serum sodium level less than 135 mmol/L, frequently associated with critical illnesses such as heart failure and liver cirrhosis, is an indicator of disease severity as well as a risk factor for poor prognosis. Hypernatremia, serum sodium level greater than 145 mmol/L, results due to any ailment disabling a patient's modality of thirst or the ability to relieve it once sensed. Hypernatremia has a more frequent iatrogenic component than hyponatremia. It can develop insidiously among patients through IV fluid administration of saline; both its presentation upon admission and development during stay is associated with mortality. Hyponatremia is associated with increased mortality and its treatment with morbidity as it carries a risk of overcorrection and consequently the development of central pontine myelinolysis. This review article covers the findings, and subsequent correlation between findings sought, of six articles catering to underscore the correlation between sodium disorders and prognosis of hospitalized or critically ill patients. PubMed search engine was utilized to select articles befitting the purpose of this review. Cumulatively, this review article substantiates the need to diligently evaluate and treat serum sodium disorders in hospitalized patients to achieve better prognosis.

The prognostic importance of serum sodium levels at hospital discharge and one-year mortality among hospitalized patients

BACKGROUND

The optimal range of serum sodium at hospital discharge is unclear. Our objective was to assess the one-year mortality based on discharge serum sodium in hospitalized patients.

METHODS

We analyzed a cohort of hospitalized adult patients between 2011 and 2013 who survived hospital admission at a tertiary referral hospital. We categorized discharge serum sodium into five groups; ≤132, 133-137, 138-142, 143-147, and ≥148 mEq/L. We assessed one-year mortality risk after hospital discharge based on discharge serum sodium, using discharge sodium of 138-142 mEq/L as the reference group.

RESULTS

Of 55 901 eligible patients, 4.9%, 29.8%, 56.1%, 8.9%, 0.3% had serum sodium of ≤132, 133-137, 138-142, 143-147, and ≥148 mEq/L, respectively. We observed a U-shaped association between discharge serum sodium and one-year mortality, with nadir mortality in discharge serum sodium of 138-142 mEq/L. When adjusting for potential confounders, including admission serum sodium, one-year mortality was significantly higher in both discharge serum sodium ≤137 and ≥143 mEq/L, compared with discharge serum sodium of 138-142 mEq/L. The mortality risk was the most prominent in elevated discharge serum sodium of ≥148 mEq/L (HR 3.86; 95% CI 3.05-4.88), exceeding the risk associated with low discharge serum sodium of ≤132 mEq/L (HR 1.43; 95% CI 1.30-1.57).

CONCLUSION

The optimal range of serum sodium at discharge was 138-142 mEq/L. Both hypernatremia and hyponatremia at discharge were associated with higher one-year mortality. The impact on higher one-year mortality was more prominent in hypernatremia than hyponatremia.