Anemia and blood transfusion and outcome on the intensive care unit

The factors associated with nosocomial infection in elderly hip fracture patients: gender, age, and comorbidity

PURPOSE

This is a retrospective case-control study to ascertain the factors influencing nosocomial infection (NI) in elderly patients with hip fractures.

METHODS

A total of 80,174 patients (≥ 60 years) who suffered hip fractures between 2006 and 2017 were identified through a national inquiry of 94 hospitals. The patients were divided into an NI group and control group according to the occurrence or lack of occurrence of NI within 48 hours after surgery, respectively. Age, gender, hip fracture pattern, whether to operate, surgical treatments, and comorbidities were recorded as variables.

RESULTS

A total of 9806 elderly hip fracture patients (60 years) were included, 1977 of whom were patients diagnosed with NI. The control group consisted of randomly drawn cases from the 9806 patients from different hospitals with a rate of one NI patient: four patients without NI. Patient gender, age, and in particular the number of comorbidities were associated with occurrence of NI. Using regression models to predict infection outcomes based on the number of comorbidities had an area under the curve (AUC) of 0.714, while using the Charlson comorbidity index (CCI) yielded a smaller value of 0.694. The most common comorbidities of this elderly cohort were chronic respiratory disease, hypertension, diabetes mellitus, cerebrovascular disease, and coronary heart disease.

CONCLUSIONS

Older age, male gender, and greater number of comorbidities were found to be associated with the occurrence of NI. In particular, the number of comorbidities was the most accurate predictor of NI occurrence, and when used to build a regression model, it had greater predictive capability than CCI to predict NI in elderly hip fracture patients. Additionally, the common diseases of the elderly should be primarily considered when investigating the relationship between comorbidities and NI in older patients.

Eosinopenia and post-hospital outcomes in critically ill non-cardiac vascular surgery patients

BACKGROUND AND AIMS

Eosinopenia is a marker for acute inflammation. We hypothesized that eosinopenia at Intensive Care Unit (ICU) admission in vascular surgery patients who receive critical care, would be associated with increased mortality following hospital discharge.

METHODS AND RESULTS

We performed a two-center observational cohort study of critically ill, non-cardiac adult vascular surgery patients who received treatment in Boston between 1997 and 2012 and survived hospital admission. The consecutive sample included 5083 patients (male 57%, white 82%, mean age [SD] 61.6 [17.4] years). The exposure was Absolute eosinophil count measured within 24 h of admission to the ICU and categorized as ≤10 cells/μL, 11-50 cells/μL, 51-100 cells/μL, 101-350 cells/μL (normal range), and >350 cells/μL. The primary outcome was all-cause mortality within 90 days of hospital discharge. The secondary outcome was discharge to home following hospitalization. 90-day post-discharge mortality was 6.7%, and 12.9% of patients were readmitted within 30 days. After multivariable adjustment, patients with eosinopenia (≤10 cells/μL) have a 90-day post-discharge mortality OR of 1.97 (95%CI 1.42, 2.73; P < 0.001) relative to patients with an absolute eosinophil count of 101-350 cells/μL. Further, after multivariable adjustment, patients with eosinopenia (≤10 cells/μL) have a 25% lower odds of discharge to home compared to patients with an absolute eosinophil count of 101-350 cells/μL [OR = 0.71 (CI 95% 0.59-0.85); P < 0.001].

CONCLUSION

Eosinopenia at ICU admission is a robust predictor of increased mortality and lower likelihood of discharge to home in vascular surgery patients treated with critical care who survive hospitalization.

Red cell distribution width at hospital discharge and out-of hospital outcomes in critically ill non-cardiac vascular surgery patients

Objective

Red cell distribution width (RDW) is associated with mortality and bloodstream infection risk in the critically ill. In vascular surgery patients surviving critical care it is not known if RDW can predict subsequent risk of all-cause mortality following hospital discharge. We hypothesized that an increase in RDW at hospital discharge in vascular surgery patients who received critical care would be associated with increased mortality following hospital discharge.

Design, setting, and participants

We performed a two-center observational cohort study of critically ill non-cardiac vascular surgery patients surviving admission 18 years or older treated between November, 1997, and December 2012 in Boston, Massachusetts.

Exposures

RDW measured within 24 hours of hospital discharge and categorized a priori as ≤13.3%, 13.3–14.0%, 14.0–14.7%, 14.7–15.8%, >15.8%.

Main outcomes and measures

The primary outcome was all cause mortality in the 90 days following hospital discharge.

Results

The cohort included 4,715 patients (male 58%; white 83%; mean age 62.9 years). 90 and 365-day post discharge mortality was 7.5% and 14.4% respectively. In the cohort, 47.3% were discharged to a care facility and 14.8% of patients were readmitted within 30 days. After adjustment for age, gender, race, Deyo-Charlson comorbidity Index, patient type, acute organ failures, prior vascular surgery and vascular surgery category, patients with a discharge RDW 14.7–15.8% or >15.8% have an adjusted OR of 90-day post discharge mortality of 2.52 (95%CI, 1.29–4.90; P = 0.007) or 5.13 (95%CI, 2.70–9.75; P <0.001) relative to patients with a discharge RDW ≤13.3%. The adjusted odds of 30-day readmission in the RDW >15.8% group was 1.52 (95%CI, 1.12–2.07; P = 0.007) relative to patients with a discharge RDW ≤13.3%. Similar adjusted discharge RDW-outcome associations are present at 365 days following hospital discharge and for discharge to a care facility.

Conclusions

In critically ill vascular surgery patients who survive hospitalization, an elevated RDW at hospital discharge is a strong predictor of subsequent mortality, hospital readmission and placement in a care facility. Patients with elevated RDW are at high risk for adverse out of hospital outcomes and may benefit from closer post discharge follow-up and higher intensity rehabilitation.

Red cell distribution width predicts out of hospital outcomes in critically ill emergency general surgery patients

Introduction

Red cell distribution width (RDW) is associated with mortality and bloodstream infection risk in critically ill patients. We hypothesized that an increase in RDW at hospital discharge in critically ill patients who received emergency general surgery (EGS) would be associated with increased mortality after hospital discharge.

Methods

We performed a two-center observational study of patients treated in medical and surgical intensive care units. We studied 1567 patients, who received critical care between 1998 and 2012 who underwent EGS and survived hospitalization. The exposure of interest was RDW within 24 hours of hospital discharge and categorized a priori in quintiles as ≤13.3%, 13.3% to 14.0%, 14.0% to 14.7%, 14.7% to 15.8%, 15.8% to 17.0% and >17.0%. The primary outcome was 90-day all-cause mortality. Adjusted ORs were estimated by multivariable logistic regression models with inclusion of covariate terms for age, race, gender, Deyo-Charlson Index, sepsis and number of organs with acute failure.

Results

The cohort patients were 51.4% male and 23.2% non-white. 23.9% had sepsis and the mean age was 58 years. 90-day postdischarge mortality was 6.8%. Patients with a discharge RDW 15.8% to 17.0% or RDW >17.0% have an adjusted OR of 90-day postdischarge mortality of 3.64 (95% CI 1.04 to 12.68; p=0.043) or 4.58 (95% CI 1.32 to 15.93; p=0.02), respectively, relative to patients with a discharge RDW ≤13.3%. Further, patients with a discharge RDW ≥15.8 have an adjusted OR of 30-day hospital readmission of 2.12 (95% CI 1.17 to 3.83; p=0.013) relative to patients with a discharge RDW ≤13.3%.

Conclusions

In EGS patients requiring critical care who survive hospitalization, an elevated RDW at the time of discharge is a robust predictor of all-cause patient mortality and hospital readmission after discharge.

Level of evidence

Level II, prognostic retrospective study.

The association of red cell distribution width at hospital discharge and out-of-hospital mortality following critical illness*

OBJECTIVES

Red cell distribution width is associated with mortality and bloodstream infection risk in the critically ill. In hospitalized patients with critical illness, it is not known if red cell distribution width can predict subsequent risk of all-cause mortality following hospital discharge. We hypothesized that an increase in red cell distribution width at hospital discharge in patients who survived to discharge following critical care would be associated with increased postdischarge mortality.

DESIGN

Two-center observational cohort study

SETTING

: All medical and surgical ICUs at the Brigham and Women's Hospital and Massachusetts General Hospital.

PATIENTS

We studied 43,212 patients, who were 18 years old or older and received critical care between 1997 and 2007 and survived hospitalization.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The exposure of interest was red cell distribution width within 24 hours of hospital discharge and categorized a priori in quintiles as less than or equal to 13.3%, 13.3-14.0%, 14.0-14.7%, 14.7-15.8%, and more than 15.8%. The primary outcome was all-cause mortality in the 30 days following hospital discharge. Secondary outcomes included 90-day and 365-day mortality following hospital discharge. Mortality was determined using the U.S. Social Security Administration Death Master File, and 365-day follow-up was present in all cohort patients. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both red cell distribution width and mortality. Adjustment included age, race, gender, Deyo-Charlson Index, patient type (medical vs surgical), sepsis, and number of organs with acute failure. In patients who received critical care and survived hospitalization, the discharge red cell distribution width was a robust predictor of all-cause mortality and remained so following multivariable adjustment. Patients with a discharge red cell distribution width of 14.0-14.7%, 14.7-15.8%, and more than 15.8% have an odds ratio for mortality in the 30 days following hospital discharge of 2.86 (95% CI, 2.25-3.62), 4.57 (95% CI, 3.66-5.72), and 8.80 (95% CI, 7.15-10.83), respectively, all relative to patients with a discharge red cell distribution width less than or equal to 13.3%. Following multivariable adjustment, patients with a discharge red cell distribution width of 14.0-14.7%, 14.7-15.8%, and more than 15.8% have an odds ratio for mortality in the 30 days following hospital discharge of 1.63 (95% CI, 1.27-2.07), 2.36 (95% CI, 1.87-2.97), and 4.18 (95% CI, 3.36-5.20), respectively, all relative to patients with a discharge red cell distribution width less than or equal to 13.3%. Similar significant robust associations post multivariable adjustments are seen with death by days 90 and 365 postdischarge. Estimating the receiver-operating characteristic area under the curve shows that discharge red cell distribution width has moderate discriminative power for mortality 30 days following hospital discharge (area under the curve = 0.70; SE 0.006; 95% CI, 0.69-0.71; p < 0.0001).

CONCLUSION

In patients treated with critical care who survive hospitalization, an elevated red cell distribution width at the time of discharge is a robust predictor of subsequent all-cause patient mortality. Increased discharge red cell distribution width likely reflects the presence of proinflammatory state, oxidative stress, arterial underfilling, or a combination, thereof which may explain the observed impact on patient survival following discharge. Elevated red cell distribution width at hospital discharge may identify ICU survivors who are at risk for adverse outcomes following hospital discharge.

Short-Term Impact of Anemia on Mortality

Objective: To estimate the short-term (14 months) impact of anemia on mortality among Mexican older adults (OAs). Method: Longitudinal analyses using data from a quasi-experimental study in a non-contributory pension program in Mexico with a sample of 3,621 OAs aged 65 to 74 years. Data on health, nutrition, life conditions, and mortality were gathered at both baseline and follow-up. Logistic regression model was used to estimate the impact of anemia and hemoglobin quintiles on mortality. Results: Overall mortality rate was 2.1%. Both mild anemia and moderate/severe anemia increased mortality risk at 14 months (odds ratio [OR] = 2.04, 95% confidence interval [CI] = [1.1, 4.1]; and OR = 6, 95% CI = [2.1, 16.9], respectively). Discussion: In the short term, degree of severity of anemia is an independent predictor of mortality risk. Because anemia is a modifiable factor, further research is required to better understand this condition in terms of main causes, prevention, treatment, and impact on OAs’ survival.