ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) II SCORE - THE CLINICAL PREDICTOR IN NEUROSURGICAL INTENSIVE CARE UNIT

Clinical Efficacy of Continuous Renal Replacement Therapy in Patients with Pulmonary Tuberculosis Complicated with Sepsis: A Retrospective Observational Study

Objective

To explore the clinical efficacy of continuous renal replacement therapy (CRRT) in patients with pulmonary tuberculosis (TB) complicated with sepsis, particularly focusing on 28-day mortality (primary objective), and to assess the impact of CRRT on inflammatory response, renal function, haemodynamics and overall prognosis (secondary objectives).

Methods

A total of 98 patients with pulmonary TB complicated by sepsis were included: 49 patients were enrolled in the control group and received routine treatment, whereas 49 patients were enrolled in the CRRT group and received CRRT based on the control group. Renal function indicators, inflammatory indicators, haemodynamic indicators and recovery status were analysed and compared.

Results

After 72 hours of treatment, C-reactive protein (CRP), serum creatinine (SCR), blood urea nitrogen (BUN) and plasma lactic in the CRRT group decreased (P < 0.001), procalcitonin (PCT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were reduced (P < 0.01) and urine volume and mean arterial pressure (MAP) increased (P < 0.001). After 72 hours of treatment, CRP and PCT in the control group increased (P < 0.05), SCR, BUN and NT-proBNP increased (P < 0.001), plasma lactic was not significantly changed and MAP decreased (P < 0.05). The 28-day mortality in the CRRT group was lower than in the control group (28.6% vs 49%, P = 0.038), intensive care unit hospitalisation time was shorter than in the control group (11.27 ± 9.34 vs 15.43 ± 9.19 d, P = 0.028) and Acute Physiological Function and Chronic Health Status Scoring System II and Sequential Organ Failure Score scores were lower after treatment (P < 0.001). The difference was statistically significant.

Conclusion

Continuous renal replacement therapy can significantly improve inflammatory response, enhance haemodynamics, promote renal function recovery and increase overall treatment efficacy in patients with pulmonary TB complicated with sepsis.

Precision medicine and patient outcomes in intensive care unit: Culture sensitivity, antibiotics, and APACHE score IV

BACKGROUND

In the intensive care unit (ICU), complex medical conditions require specialized care; the threat of antibiotic resistance is significant due to frequent antibiotic use. This study investigates the pivotal role of culture sensitivity testing in shaping antibiotic prescription practices and patient outcomes in ICUs.

MATERIALS AND METHODS

By using a prospective observational-analytical design, medical data from 640 patients at a Karachi hospital for one year in 2022 were utilized. The study focused on antibiotic therapy, including empiric and targeted approaches, culture sensitivity testing, the use of the APACHE scale for mortality prediction, and changes in antibiotic regimens based on culture reports. Statistical analysis involved Fisher's Exact and ANOVA tests.

RESULT

The age category above 60 emerged with the highest survivorship. Contrary to expectations, age did not seem to correlate significantly with mortality rates. Staphylococcus species was the most prevalent microorganism in this study, disproportionately affecting nonsurvivors 66.7%. The clinical profile comparison between survivors and nonsurvivors offered a multifaceted perspective, with significant differences in vital parameters such as temperature, heart rate, respiratory rate, urine output, FiO2, mean arterial pH, and blood sugar levels. Survivors (44.60%) underwent complete antibiotic regimen changes, a strategy for improved patient outcomes.

CONCLUSIONS

Complex antibiotic combinations were prescribed for broad clinical conditions. These insights pave the way for future research on antibiotic stewardship in ICUs, navigating more effective and targeted treatments.

Comparative analysis of the postadmission and antemortem oropharyngeal and rectal swab microbiota of ICU patients

Shotgun metabarcoding was conducted to examine the microbiota in a total of 48 samples from 12 critically ill patients, analyzing samples from both the oropharynx and rectum. We aimed to compare their postadmission microbiota, characterized as moderately dysbiotic, with the severely dysbiotic antemortem microbiota associated with patients' deaths. We found that, compared with postadmission samples, patient antemortem swab samples presented moderate but not significantly decreased diversity indices. The antemortem oropharyngeal samples presented an increase in biofilm-forming bacteria, including Streptococcus oralis, methicillin-resistant Staphylococcus aureus (MRSA), and Enterococcus faecalis. Although the septic shock rate was 67%, no significant differences were detected in the potential pathogen ratios when the microbiota was analyzed. A notable strain-sharing rate between the oropharynx and intestine was noted. By comparing postadmission and antemortem samples, microbial biomarkers of severe dysbiosis were pinpointed through the analysis of differentially abundant and uniquely emerging species in both oropharyngeal and rectal swabs. Demonstrating strong interconnectivity along the oral-intestinal axis, these biomarkers could serve as indicators of the progression of dysbiosis. Furthermore, the microbial networks of the oropharyngeal microbiota in deceased patients presented the lowest modularity, suggesting a vulnerable community structure. Our data also highlight the critical importance of introducing treatments aimed at enhancing the resilience of the oral cavity microbiome, thereby contributing to better patient outcomes.

Mortality rate analysis of patients on invasive mechanical ventilation in the intensive care unit on day 28

Outcomes in patients receiving invasive mechanical ventilation (IMV) are currently unclear. The present study aimed to explore the prognostic factors of the mortality rate on day 28 in patients treated in the intensive care unit (ICU) and undergoing IMV. The IMV Mortality Prediction Score (IMPRES) of 129 patients in the ICU receiving IMV after emergency (or selective) endotracheal intubation from March 2018 to August 2020 was calculated. The patients were divided into survival (n=73) and death groups (n=56) on day 28. The predictive factors of independent and combined mortality rates were determined using a receiver operating characteristic (ROC) curve and the area under the ROC curve (AUC). The AUC of the IMPRES for predicting patient death on day 28 was 0.785 (95% confidence interval (CI): 0.704-0.864, P<0.01). When the IMPRES cut-off was 4.50, the Youden index was at its maximum (0.487) with a sensitivity of 85.7% and a specificity of 63.0%. The AUC of the ventilator use time (days) at 12.5 days cut-off was 0.653 (95% CI: 0.56-0.746, P<0.01), the Youden index was 0.235 with a sensitivity of 52.1% and a specificity of 71.4%. The AUC of the IMPRES combined with the duration of ventilator use was 0.856 (95% CI: 0.789-0.922, P<0.001), the Youden index was 0.635 with a sensitivity of 84.9% and a specificity of 78.6%. The IMPRES was observed to be the main factor influencing the mortality rate of patients receiving IMV at the ICU on day 28, and the IMPRES combined with the duration of ventilator use had a significant predictive value for the 28-day mortality rates of these patients.

Clinical Characteristics and Prognosis of ICU-Admitted Patients with Guillain-Barre Syndrome: A Report from a Large Teaching Hospital in South Iran

Background

Guillain-Barre Syndrome (GBS) is the most prevalent acute peripheral polyneuropathy disorder. The disparities between populations and variations in the major risk factors highlight the importance of country-specific studies. This study aimed to report clinical characteristics and outcomes of ICU-admitted patients with GBS in an academic medical center in Iran.

Methods

The data were collected retrospectively from all patients with GBS admitted to Namazi Hospital, affiliated with Shiraz University of Medical Sciences, (Shiraz, Iran), between March 2016 to March 2021. Specialized neurological information and the Acute Physiology and Chronic Health Evaluation (APACHE II) score were recorded. The SPSS software was used to analyze the data. The analyzed data were reported as numbers and percentages, or mean±SD, or median(Interquartile).

Results

The study included 132 GBS patients, with an average age of 47.87±15.4 years and a male-to-female ratio of 1.69:1. More than half of the patients (58.5%) were classified as having an axonal disease. In patients with axonal illness, 51.4% of patients had lower limb powers<3, while only 36% of those had the demyelinating disease. This group also required mechanical ventilation more frequently (54% vs. 46%) and for a longer duration (26 [9-37] vs. 10 [1-61]) days. Pneumonia and sepsis were each observed in 16% of patients, and 12% developed a urinary tract infection. The most common type of GBS was acute inflammatory demyelinating polyneuropathy (AIDP). Only 6 (3.8%) patients died.

Conclusion

The axonal type of GBS was more frequent, and these patients required mechanical ventilation more frequently and for a longer duration than those in other electrophysiological categories. A preprint version of the manuscript is available at DOI: https://doi.org/10.21203/rs.3.rs-2181605/v1.

Predictors of Treatment Failure and Mortality among Patients with Septic Shock Treated with Meropenem in the Intensive Care Unit

Background

The aim of the study was to determine the predictors of meropenem treatment failure and mortality in the Intensive Care Unit (ICU).

Methods

This was a retrospective study, involving sepsis and septic shock patients who were admitted to the ICU and received intravenous meropenem. Treatment failure is defined as evidence of non-resolved fever, non-reduced total white cell (TWC), non-reduced C-reactive protein (CRP), subsequent culture negative and death in ICU.

Results

An Acute Physiology and Chronic Health Evaluation II (APACHE II) and duration of antibiotic treatment less than 5 days were associated with treatment failure with adjusted OR = 1.24 (95% CI: 1.15, 1.33; P < 0.001), OR = 65.43 (95% CI: 21.70, 197.23; P < 0.001). A higher risk of mortality was observed with higher APACHE and Sequential Organ Failure Assessment (SOFA) scores, initiating antibiotics > 72 h of sepsis, duration of antibiotic treatment less than 5 days and meropenem with renal adjustment dose with an adjusted OR = 1.21 (95% CI: 1.12, 1.30; P < 0.001), adjusted OR = 1.23 (95% CI: 1.08, 1.41; P < 0.001), adjusted OR = 6.38 (95% CI: 1.67, 24.50; P = 0.007), adjusted OR = 0.03 (95% CI: 0.01, 0.14; P < 0.001), adjusted OR = 0.30 (95% CI: 0.14, 0.64; P = 0.002).

Conclusion

A total of 50 (14.12%) patients had a treatment failure with meropenem with 120 (48.02%) ICU mortality. The predictors of meropenem failure are higher APACHE score and shorter duration of meropenem treatment. The high APACHE, high SOFA score, initiating antibiotics more than 72 h of sepsis, shorter duration of treatment and meropenem with renal adjustment dose were predictors of mortality.

Clinical Characteristics and Outcomes of Neurosurgical Patients at a Level III Intensive Care Unit in Pakistan: A Retrospective Cohort Study

Objective Neurosurgical patients account for the majority of cases across all surgical specialties that are admitted to the surgical intensive care unit (ICU) at our institution. The goal of this study was to analyze factors leading to ICU admission, type of neurosurgical intervention, length of ICU/hospital stays, and outcomes in terms of complications and ICU and in-hospital mortality. Methods This retrospective study conducted at the surgical ICU, Aga Khan University Hospital, investigated clinical data of neurosurgical patients admitted between January 2020 and June 2022. Quantitative data were collected regarding patients' characteristics, such as age, gender, comorbidities, type of surgical intervention, mode of surgery, source of admission to ICU, and type of osmotherapy. The primary and secondary outcomes were in terms of ICU and hospital mortality and complications. Results Among 321 patients admitted to the SICU, 197 were included according to inclusion/exclusion criteria. A total of 168 patients (85.3%) required surgical intervention, of whom 101 (60%) underwent elective surgery and 67 (40%) required emergency surgery. Thirteen patients died during the ICU or hospital stay, representing a mortality rate of 6.6%. The average length of stay in the ICU had a median IQR of 4 (4,6) days while the average hospital stay median IQR was 11 (12,18) days. Tracheostomy was performed in 77 patients (39%), and the median IQR day for tracheostomy was 4 (3,5) days. APACHE-II (Acute Physiology and Chronic Health Evaluation) score, length of ICU, and length of hospital stay were significantly higher in the deceased patients with a p-value of 0.042, 0.019, and 0.043, respectively. Conclusion In conclusion, this study on neurosurgical patients from the surgical intensive care unit of a low-middle-income country provided valuable insights about factors and their influence on outcomes. The study implies that a high APACHE-II score is linked to poorer outcomes for neurosurgical patients in this particular setting. Undertaking a large multicenter prospective study is vital for tailoring interventions and improving patient care in regions with limited resources where healthcare challenges may be distinct.

Acute Kidney Injury in Patients Undergoing Extracorporeal Membrane Oxygenation: A Retrospective Cohort Study

Aims and background

Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal therapy to support oxygenation of patients with severe cardiac or respiratory failure. Studies have shown that acute kidney injury (AKI) can worsen the outcome in these patients. This study aims to assess the incidence and outcome of AKI in patients on ECMO support.

Materials and methods

This retrospective study included 64 patients who underwent ECMO for more than 24 hours. Patients who died within 48 hours of initiation of ECMO and patients with end-stage renal disease (ESRD) on maintenance hemodialysis were excluded. Acute kidney injury was diagnosed and categorized according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.

Results

Of the 64 patients studied, 38 patients (59.38%) developed AKI and 17 patients (44.73%) among them developed AKI within 24 hours of initiation of ECMO. Age, Acute Physiology and Chronic Health Evaluation (APACHE-II) score, hypertension, use of nephrotoxic agents, inotropic support, and poor cardiac function were the risk factors associated with the development of AKI. Diabetes mellitus, type of ECMO used, and duration of ECMO were not found to be risk factors for AKI. Renal replacement therapy was initiated in 31 patients (81.58%). The overall mortality in the whole group was 67.19%, while it was 81.58% among the patients with AKI.

Conclusion

Acute kidney injury was found to be an independent risk factor for mortality in patients on ECMO. Early identification of the risk factors for AKI and management may help to improve the survival rate.

Clinical significance

The occurrence of AKI among patients on ECMO support increases the risk of mortality significantly. Hence, measures to prevent AKI, as well as early detection and appropriate management of AKI, would improve patient outcomes.

How to cite this article

Surjit A, Prasannan B, Abraham J, Balagopal A, Unni VA. Acute Kidney Injury in Patients Undergoing Extracorporeal Membrane Oxygenation: A Retrospective Cohort Study. Indian J Crit Care Med 2024;28(1):26-29.

GLUCOSE AND SODIUM LEVELS AS DISEASE OUTCOME PREDICTORS IN CRITICALLY ILL PATIENTS

The main aim of this study was to examine the association of glucose and sodium level with diagnosis and disease outcome of critically ill patients. Glucose and sodium concentrations of 283 patients admitted in critical condition to the Intensive Care Unit of the Department of Internal Medicine in a period from November 1, 2015 to February 28, 2017 were reviewed. The most common diagnoses in critically ill patients were acute kidney injury (26.1%) and sepsis (including septic shock, 22.3%). Significantly lower glucose concentration was observed in patients with acute kidney injury (p=0.02), whereas patients in sepsis and septic shock had a significantly higher sodium concentration (p=0.04). Higher glucose level was related to higher mortality rate (p=0.001). On the other hand, sodium level was not significantly associated with survival. Higher mortality, as well as higher glucose concentration were more common in patients older than 65 years (p<0.001). Study results showed significantly lower glucose concentrations in patients with acute kidney injury, whereas in patients older than 65, glucose concentration was significantly higher. Patients in sepsis and septic shock had significantly higher sodium concentrations. Higher concentration of glucose was connected with higher mortality in the elderly, whereas sodium concentration did not show connection with mortality.

Ulinastatin combined with somatostatin enhances disease control and modulates serum inflammatory factors in patients with severe pancreatitis

OBJECTIVE

This study was designed to explore the effects of ulinastatin combined with somatostatin on disease control and serum inflammatory factors in patients with severe pancreatitis.

METHODS

The data of 80 patients with severe pancreatitis treated in the First Affiliated Hospital of Jiangxi Medical College from May 2020 to April 2022 were analyzed retrospectively. Among them, 36 patients treated with somatostatin alone (3 mg somatostatin added in 50 mL normal saline) on the basis of standard treatment were assigned to a control group, and the other 44 patients treated with both ulinastatin (100,000 U of ulinastatin injection added in 250 mL 5% glucose solution) and somatostatin (3 mg somatostatin added in 50 mL normal saline) were enrolled into a study group. The levels of serum inflammatory factors (interleukin-1β (IL-1β), interleukin-6 (IL-6), and soluble intercellular adhesion molecule-1 (sICAM-1)), biochemical indexes (C-reactive protein, white blood cell count, and serum amylase) and gastrointestinal function indexes (motilin and gastrin) in the two groups were analyzed and compared before and after treatment. Additionally, the alleviation of clinical symptoms, treatment response and occurrence of adverse reactions were compared between the two groups. The mortality rate of patients within 1 month after the treatment was evaluated, and the risk factors affecting the prognosis were analyzed through logistics regression.

RESULTS

Before treatment, there was no significant difference between the two groups in the levels of IL-1β, IL-6 and sICAM-1 (P>0.05), while after treatment, the levels of all three factors decreased significantly in both groups (P<0.0001), with more notable decreases in the study group than those in the control group (P<0.0001). Before treatment, the two groups were not significantly different in the levels of C-reactive protein, white blood cell count, and serum amylase (P>0.05), while after treatment, all the three levels decreased notably in both groups (P<0.0001), with notably lower levels in the study group than those in the control group (P<0.0001). Before treatment, the levels of motilin and gastrin in the two groups were not significantly different (P>0.05), while after treatment, motilin increased significantly and gastrin decreased significantly in both groups (P<0.0001), and the study group showed a notably higher motilin level and a notably lower gastrin level than the control group (P<0.0001). The study group experienced a significantly earlier disappearance time of abdominal distension and abdominal pain and a significantly shorter hospitalization time than the control group (P<0.0001). Moreover, the study group showed a notably higher overall response rate than the control group (P=0.029), and presented a notably lower incidence of adverse reactions than the control group (P=0.036). According to univariate analysis, age, onset time, Acute Physiology and Chronic Health Evaluation II score and therapeutic regimen were the factors impacting the patients' prognosis. According to logistics regression analysis, therapeutic regimen was an independent risk factor affecting the prognosis.

CONCLUSION

Compared with somatostatin alone, ulinastatin combined with somatostatin is more effective in the treatment of severe pancreatitis. The combination can substantially alleviate the inflammatory response and improve the gastrointestinal function and clinical symptoms of patients, without increasing adverse reactions. Therefore, ulinastatin combined with somatostatin is worthy of clinical promotion.

Comparison of predictive scoring systems in patients hospitalized in the internal medicine intensive care unit

Aim: Various scoring systems have been developed to predict mortality, disease severity, and length of stay of patients in intensive care units. It is important to demonstrate the validity of these scores in the society in which they are used. This study aims to evaluate the effects of The Acute Physiologic and Chronic Evaluation (APACHE)-II, APACHE-IV, The Simplified Acute Physiologic Score (SAPS), and Mortality Prediction Model (MPM0) scores on mortality in the internal medicine intensive care unit. Material and Method: The patients who were followed up in an internal medicine intensive care unit between June 2021 and December 2021 in a tertiary hospital in Turkey were included in this study. The scores were calculated at the time they were admitted to the intensive care unit. 115 patients who were followed up in the internal medicine intensive care unit for 6 months were included. The patients were divided into two groups alive or deceased. 52 (45.2%) patients in the survivor group and 63 (54.8%) patients in the deceased group were included. Patients received no study-related medical intervention. Results: When all four prognostic scoring systems were analyzed according to the median cut-off values, rising values ​​were related to mortality with statistical significance (p

Application of Visual Artificial Airway in Patients with ARDS Assisted by Pulmonary Ultrasound

Objective

To explore the application of pulmonary ultrasound in visual nursing of artificial airway in patients with acute respiratory distress syndrome (ARDS).

Methods

Seventy-eight ARDS patients with mechanical ventilation admitted from February 2021 to January 2022 were included and divided into the intervention group and the control group. The control group was given routine airway nursing, and the intervention group was given visual airway nursing management through lung ultrasound. The arterial blood gas analysis indexes, mechanical ventilation time, ICU treatment time, total hospitalization time, aspiration, and the incidence of ventilator-associated pneumonia (VAP) were compared between the two groups.

Results

After treatment, PaO2, PaCO2, SPO2, and oxygenation indexes were significantly improved compared with those before treatment, and the indexes in the intervention group were better than those in the control group after treatment, and the differences were statistically significant (P < 0.05). The mechanical ventilation time (5.39 ± 0.68 vs. 7.92 ± 0.59 days), ICU treatment time (8.05 ± 1.14 vs. 10.71 ± 1.16 days), and total hospitalization time (12.05 ± 2.20 vs. 15.68 ± 2.18 days) in the intervention group were significantly shorter than those in the control group (P < 0.05). The incidences of aspiration (2.56% vs. 15.38%) and VAP (5.13% vs. 20.51%) in the intervention group was significantly lower than that in the control group (P < 0.05).

Conclusion

The application of visual artificial airway management assisted by lung ultrasound in ARDS patients can shorten the treatment time and hospitalization time of mechanical ventilation, reduce the incidence of aspiration and VAP, and improve the prognosis of patients.

Risk Factors and Outcome of Sepsis in Traumatic Patients and Pathogen Detection Using Metagenomic Next-Generation Sequencing

Objective

Sepsis, a life-threatening clinical syndrome, is a leading cause of mortality after experiencing multiple traumas. Once diagnosed with sepsis, patients should be given an appropriate empiric antimicrobial treatment followed by the specific antibiotic therapy based on blood culture due to its rapid progression to tissue damage and organ failure. In this study, we aimed to analyze the risk factors and outcome of sepsis in traumatic patients and to investigate the performance of metagenomic next-generation sequencing (mNGS) compared with standard microbiological diagnostics in post-traumatic sepsis.

Methods

The study included 528 patients with multiple traumas among which there were 142 cases with post-traumatic sepsis. Patients' demographic and clinical data were recorded. The outcome measures included mortality during the emergency intensive care unit (EICU), EICU length of stay (LOS), all-cause 28-day mortality, and total ventilator days in 28 days after admission. A total of 89 blood samples from 89 septic patients underwent standard microbiological blood cultures and 89 samples of peripheral blood (n = 21), wound secretion (n = 41), bronchoalveolar lavage fluid (BALF) (19), ascites (n = 5), and sputum (n = 3) underwent mNGS. Pathogen detection was compared between standard microbiological blood cultures and mNGS.

Results

The sepsis group and non-sepsis group exhibited significant differences regarding shock on admission, blood transfusion, mechanical ventilation, body temperature, heart rate, WBC count, neutrophil count, hematocrit, urea nitrogen, creatinine, CRP, D-D dimer, PCT, scores of APACHE II, sequential organ failure assessment (SOFA), and Injury Severity Score (ISS) on admission to the EICU, and Multiple Organ Dysfunction Syndromes (MODS) (P < 0.05). Multivariate logistic regression analysis showed that scores of APACHE II, SOFA, and ISS on admission, and MODS were independent risk factors for the occurrence of sepsis in patients with multiple traumas. The 28-day mortality was higher in the sepsis group than in the non-sepsis group (45.07% vs. 19.17%, P < 0.001). The mortality during the EICU was higher in the sepsis group than in the non-sepsis group (P=0.002). The LOS in the EICU in the sepsis group was increased compared with the non-sepsis group (P=0.004). The total ventilator days in 28 days after admission in the sepsis group was increased compared with the non-sepsis group (P < 0.001). Multivariate logistic regression analysis showed that septic shock, APACHE II score on admission, SOFA score, and MODS were independent risk factors of death for patients with post-traumatic sepsis. The positive detection rate of mNGS was 91.01% (81/89), which was significantly higher than that of standard microbiological blood cultures (39.33% (35/89)). Standard microbiological blood cultures and mNGS methods demonstrated double positive results in 33 (37.08%) specimens and double-negative results in 8 (8.99%) specimens, while 46 (51.69%) samples and 2 (2.25%) samples had positive results only with mNGS or culture alone, respectively.

Conclusion

Our study identifies risk factors for the incidence and death of sepsis in traumatic patients and shows that mNGS may serve as a better diagnostic tool for the identification of pathogens in post-traumatic sepsis than standard microbiological blood cultures.

Electroacupuncture in Treatment of Acute Gastrointestinal Injury in Patients with Severe Traumatic Brain Injury: A Multicenter Randomized Controlled Trial

OBJECTIVE

To evaluate whether electroacupuncture (EA) would improve gastrointestinal function and clinical prognosis in patients with severe traumatic brain injury (TBI) complicocted by acute gastrointestinal injury (AGI).

METHODS

This multicenter, single-blind trial included patients with TBI and AGI admitted to 5 Chinese hospitals from September 2018 to December 2019. A total of 500 patients were randomized to the control or acupuncture groups using a random number table, 250 cases in each group. Patients in the control group received conventional treatment, including mannitol, nutritional support, epilepsy and infection prevention, and maintenance of water, electrolytes, and acid-base balance. While patients in the acupuncture group received EA intervention at bilateral Zusanli (ST 36), Shangjuxu (ST 37), Xiajuxu (ST 39), Tianshu (ST 25), and Zhongwan (RN 12) acupoints in addition to the conventional treatment, 30 min per time, twice daily, for 7 d. The primary endpoint was 28-d mortality. The secondary endpoints were serum levels of D-lactic acid (D-lac), diamine oxidase (DAO), lipopolysaccharide (LPS), motilin (MTL) and gastrin (GAS), intra-abdominal pressure (IAP), bowel sounds, abdominal circumference, AGI grade, scores of gastrointestinal failure (GIF), Glasgow Coma Scale (GCS), Acute Physiology and Chronic Health Evaluation (APACHE II), Sequential Organ Failure Assessment (SOFA), and Multiple Organ Dysfunction Syndrome (MODS), mechanical ventilation time, intense care unit (ICU) stay, and the incidence of hospital-acquired pneumonia.

RESULTS

The 28-d mortality in the acupuncture group was lower than that in the control group (22.80% vs. 33.20%, P<0.05). Compared with the control group, the acupuncture group at 7 d showed lower GIF, APACHE II, SOFA, MODS scores, D-lac, DAO, LPS, IAP, and abdominal circumference and higher GCS score, MTL, GAS, and bowel sound frequency (all P<0.05). In addition, the above indices showed simillar changes at 7 d compared with days 1 and 3 (all P<0.05) in the EA group.

CONCLUSION

Early EA can improve gastrointestinal function and clinical prognosis in patients with severe TBI complicated by AGI. (Registration No. ChiCTR2000032276).

Predictive Value of Sequential Organ Failure Assessment (SOFA), Quick Sequential Organ Failure Assessment (qSOFA), Acute Physiology and Chronic Health Evaluation (APACHE II), and New Early Warning Signs (NEWS-2) Scores Estimate Mortality of COVID-19 Patients Requiring Intensive Care Unit (ICU)

Introduction

Various mortality predictive score models for coronavirus disease-2019 (COVID-19) have been deliberated. We studied how sequential organ failure assessment (SOFA), quick sequential organ failure assessment (qSOFA), acute physiology and chronic health evaluation II (APACHE II), and new early warning signs (NEWS-2) scores estimate mortality in COVID-19 patients.

Materials and methods

We conducted a prospective cohort study of 53 patients with moderate-to-severe COVID-19. We calculated qSOFA, SOFA, APACHE II, and NEWS-2 on initial admission and re-evaluated on day 5. We performed logistic regression analysis to differentiate the predictors of qSOFA, SOFA, APACHE II, and NEWS-2 scores on mortality.

Result

qSOFA, SOFA, APACHE II, and NEWS-2 scores on day 5 exhibited a difference between survivors and nonsurvivors (p <0.05), also between ICU and non-ICU admission (p <0.05). The initial NEWS-2 revealed a higher AUC value than the qSOFA, APACHE II, and SOFA score in estimating mortality (0.867; 0.83; 0.822; 0.794). In ICU, APACHE II score revealed a higher AUC value than the SOFA, NEWS-2, and qSOFA score (0.853; 0.832; 0.813; 0.809). Concurrently, evaluation on day 5 showed that qSOFA AUC had higher scores than the NEWS-2, APACHE II, and SOFA (0.979; 0.965; 0.939; 0.933) in predicting mortality, while SOFA and APACHE II AUC were higher in ICU admission than NEWS-2 and qSOFA (0.968; 0.964; 0.939; 0.934). According to the cutoff score, APACHE II on day 5 revealed the highest sensitivity and specificity in predicting the mortality (sensitivity 95.7%, specificity 86.7%).

Conclusion

All scores signify good predictive values on COVID-19 patients mortality following the evaluation on the day 5. Nonetheless, APACHE-II appears to be the best at predicting mortality and ICU admission rate.

How to cite this article

Asmarawati TP, Suryantoro SD, Rosyid AN, Marfiani E, Windradi C, Mahdi BA, et al. Predictive Value of Sequential Organ Failure Assessment, Quick Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and New Early Warning Signs Scores Estimate Mortality of COVID-19 Patients Requiring Intensive Care Unit. Indian J Crit Care Med 2022;26(4):464–471.

The Effect of Pulmonary Rehabilitation on Respiratory Functions, and the Quality of Life, following Coronary Artery Bypass Grafting: A Randomised Controlled Study

Objective

Examining the effects of a pulmonary rehabilitation (PR) program applied to patients undergoing coronary artery bypass grafting (CABG) surgery with open heart technique on respiratory functions, functional capacity, and quality of life (QoL).

Design

This randomised controlled study applied the Consolidated Standards of Reporting Trials statement.

Methods

The study was conducted with two groups: the intervention group (n = 25) and the control group (n = 25). The control group received standard care after coronary artery bypass grafting. On the contrary, the experimental group participated in a PR program created by the researchers in addition to standard care. After coronary artery bypass grafting, the respiratory functions (on the 4th day of clinical care) and QoL (at the 6^th week) of both groups were evaluated. The primary outcome measure was the respiratory function (forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC). The secondary outcome measure of this study was the QoL.

Results

When the average pulmonary function test values of the patients were examined, the mean FVC and FEV1 values of the patients in the intervention group on the 4th day of clinical care were significantly higher with a medium level size effect than the control group (p = 0.027; effect size (d) = 0.643; p < 0.024; effect size (d) = 0.658, respectively). At the postoperative 6th week measurement of QoL, a decrease was observed in all subdimensions of the scale, albeit less in the intervention group (p < 0.05). There was a decrease in both the mental and physical component summary of QoL (p < 0.05).

Conclusion

The results of this study revealed that pulmonary rehabilitation applied to patients who have undergone coronary artery bypass graft recover their functional capacity faster.

Early diagnosis of serum sICAM-1 and sRAGE in severe acute pancreatitis, and efficacy and prognosis prediction of glutamine combined with ulinastatin

Acute pancreatitis (AP) is a common gastrointestinal disease that can become severe, so that intensive care may be required. This study was to examine serum soluble intercellular adhesion molecule-1 (sICAM-1), and soluble receptor for advanced glycation end products (sRAGE) for efficacy and prognosis prediction of glutamine (Glu) combined with ulinastatin (UTI) on severe acute pancreatitis (SAP). Fifty-four mild acute pancreatitis (MAP) patients admitted to Yidu Central Hospital of Weifang were selected as the MAP group (MAPG), 80 with SAP were divided as the SAP group (SAPG), and 60 healthy individuals who came to Yidu Central Hospital of Weifang for physical examination during the same period were included to the normal group (NG). Serum sICAM-1 and sRAGE were measured and their predictive value of efficacy and prognosis were analyzed. In view of the treatment effectiveness and prognosis, the patients were divided into effective group (EG) and ineffective group (IG), good prognosis group (GPG) and poor prognosis group (PPG). The levels of D-lactate, diamine oxidase (DAO), endotoxin and T-lymphocyte subsets (CD3⁺, CD4⁺, CD8⁺ and CD4⁺/CD8⁺) were measured and the changes before and after treatment were analyzed. The AUC values of NG and MAPG, NG and SAPG, MAPG and SAPG were 0.857, 0.939 and 0.856, respectively, those of predicting efficacy were 0.920 and 0.874, respectively, and those of poor prognosis in the SAPG were 0.914 and 0.879, respectively. In the SAPG, D-lactate, DAO, endotoxin and CD8⁺ decreased markedly after treatment, but CD3⁺, CD4⁺, and CD4⁺/CD8⁺ were opposite. SICAM-1 and sRAGE were also independent risk factors for poor prognosis in the SAPG. Serum sICAM-1 and sRAGE have high predictive value for early diagnosis, efficacy and prognosis of Glu combined with UTI.

The predictive prognostic values of serum interleukin-2, interleukin-6, interleukin-8, tumor necrosis factor-α, and procalcitonin in surgical intensive care unit patients

Background

The pathophysiological roles of serum cytokine levels in critically ill surgical patients has yet to be determined. This study aimed to determine the predictive prognostic values of serum interleukin IL-2, IL-6, IL-8, tumor necrosis factor-α (TNF-α), and procalcitonin (PCT) in surgical intensive care unit (ICU) patients.

Methods

Cytokine concentrations were measured with an IMMULITE 1000 Immunoassay System (Siemens Healthcare Diagnostics GmbH, Berlin, Germany). The study population was divided into quartiles according to the patients’ cytokine levels: Q1, Q2, Q3, and Q4. The optimal cutoff values of IL-2, IL-6, IL-8, TNF-α, and PCT level for predicting mortality were established by drawing receiver operating characteristic curves.

Results

The levels of IL-2 in Q3 [odds ratio (OR) =4.434, 95% confidence intervals (95% CI): 1.527–12.874] and Q4 (OR =7.715, 95% CI: 2.744–21.693) were significantly higher than those in the Q1. The same results were noted in IL-6 and IL-8, and only Q4 (OR =2.383, 95% CI: 1.419–4.001) showed significance in the level of TNF-α. For IL-2, a cutoff value of 930.5 U/mL yielded a sensitivity of 69.39% and a specificity of 80.16% for the prediction of clinical outcome [area under the curve (AUC): 0.822; 95% CI: 0.789–0.855]. For IL-6, a cutoff value of 50.95 pg/mL showed discrimination ability, yielding a sensitivity of 71.43% and a specificity of 61.75% for (AUC: 0.704; 95% CI: 0.660–0.748). For IL-8, a cutoff value of 44.1 pg/mL yielded a sensitivity of 57.82% and a specificity of 79.58% for predicting clinical outcome (AUC: 0.753; 95% CI: 0.713–0.793). For TNF-α, a cutoff value of 11.95 pg/mL yielded a sensitivity and specificity of 68.66% and 72.90%, respectively, in predicting clinical outcome (AUC: 0.758; 95% CI: 0.717–0.800). The positive likelihood ratios for IL-2, IL-6, IL-8, and TNF-α were 3.50, 1.87, 2.83 and 2.53, and the negative likelihood ratios were 0.38, 0.46, 0.53, and 0.43, respectively.

Conclusions

In critically ill patients, high levels of IL-2, IL-6, IL-8, and TNF-α in the first 24 h postoperatively were associated with clinical outcome. However, the effect of PCT level on prognosis still requires further study.