Activin A level is associated with physical function in critically ill patients

BACKGROUND

Activin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels.

OBJECTIVES

The objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital.

METHODS

Thirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for >48 h and expected to have a total ICU stay of >5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU.

RESULTS

High peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: -91.3, -154.2 to -28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures.

CONCLUSIONS

Higher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness.

STUDY REGISTRATION

ACTRN12615000047594.

Predictors of acute hospital mortality and length of stay in patients with new-onset atrial fibrillation: a first-hand experience from a medical emergency team response provider

BACKGROUND

Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management.

AIM

To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF.

METHODS

The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality.

RESULTS

New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 ± 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059).

CONCLUSION

Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.

Severe acute maternal morbidity trends in Victoria, 2001-2017

BACKGROUND

The incidence of severe acute maternal morbidity (SAMM) is one method of measuring the complexity of maternal health and monitoring maternal outcomes. Monitoring trends may provide a quantitative method for assessing health care at local, regional, or jurisdictional levels and identify issues for further investigation.

AIMS

Identify temporal trends for SAMM event rates and maternal outcomes over 17 years in the state of Victoria, Australia.

MATERIALS AND METHODS

All maternal public health service admissions were extracted from an administrative dataset from July 2000 to June 2017. SAMM-related diagnoses were defined by matching as closely as possible with published definitions. Outcomes included annual SAMM event rates, hospital survival, and hospital length of stay (LOS). Temporal trends were analysed using mixed-effects generalised linear models.

RESULTS

There were 854 777 live births and 1.21 million pregnancy-related hospital admissions which included 34 008 SAMM events in 29 273 records and in 3.42% (95%CI = 3.39-3.46) of births. Most common were severe pre-eclampsia (0.87% of births), severe postpartum haemorrhage (0.59%), and sepsis (0.62%). SAMM-related admissions were associated with longer LOS and higher mortality risk (P < 0.001). Maternal mortality ratio remained unchanged at 8.6 fatalities per 100 000 births (P = 0.65).

CONCLUSION

Over 17 years, there was a significant increase in birth rate and SAMM-related events in Victoria. Administrative data may provide a pragmatic approach for monitoring SAMM-related events in maternal health services.

Risk factors for mortality in patients admitted to intensive care units with pneumonia

Background

Despite the high mortality in patients with pneumonia admitted to an ICU, data on risk factors for death remain limited.

Methods

In this secondary analysis of PROTECT (Prophylaxis for Thromboembolism in Critical Care Trial), we focused on the patients admitted to ICU with a primary diagnosis of pneumonia. The primary outcome for this study was 90-day hospital mortality and the secondary outcome was 90-day ICU mortality. Cox regression model was conducted to examine the relationship between baseline and time-dependent variables and hospital and ICU mortality.

Results

Six hundred sixty seven patients admitted with pneumonia (43.8 % females) were included in our analysis, with a mean age of 60.7 years and mean APACHE II score of 21.3. During follow-up, 111 patients (16.6 %) died in ICU and in total, 149 (22.3 %) died in hospital. Multivariable analysis demonstrated significant independent risk factors for hospital mortality including male sex (hazard ratio (HR) = 1.5, 95 % confidence interval (CI): 1.1 - 2.2, p-value = 0.021), higher APACHE II score (HR = 1.2, 95 % CI: 1.1 - 1.4, p-value < 0.001 for per-5 point increase), chronic heart failure (HR = 2.9, 95 % CI: 1.6 - 5.4, p-value = 0.001), and dialysis (time-dependent effect: HR = 2.7, 95 % CI: 1.3 - 5.7, p-value = 0.008). Higher APACHE II score (HR = 1.2, 95 % CI: 1.1 - 1.4, p-value = 0.002 for per-5 point increase) and chronic heart failure (HR = 2.6, 95 % CI: 1.3 – 5.0, p-value = 0.004) were significantly related to risk of death in the ICU.

Conclusion

In this study using data from a multicenter thromboprophylaxis trial, we found that male sex, higher APACHE II score on admission, chronic heart failure, and dialysis were independently associated with risk of hospital mortality in patients admitted to ICU with pneumonia. While high illness severity score, presence of a serious comorbidity (heart failure) and need for an advanced life support (dialysis) are not unexpected risk factors of mortality, male sex might necessitate further exploration. More studies are warranted to clarify the effect of these risk factors on survival in critically ill patients admitted to ICU with pneumonia.

Trial registration

ClinicalTrials.gov Identifier: NCT00182143.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-016-0397-5) contains supplementary material, which is available to authorized users.

Mechanical ventilation in critically-ill pregnant women: a case series

BACKGROUND

Approximately 0.1-0.2% of pregnancies are complicated by respiratory failure requiring mechanical ventilatory support, but few data exist to inform clinical management. This study aimed to characterize current practice and the effect of delivery on respiratory function.

METHODS

A retrospective review was performed of pregnant women who received mechanical ventilation for more than 24h, from four intensive care units in institutions with large-volume obstetric units.

RESULTS

Data were collected from 29 patients with a mean gestation at intensive care unit admission of 25.3 ± 6 weeks. Tidal volumes were 7.7 ± 1.7 mL/kg predicted body weight. Estimated respiratory system compliance was reduced, but was higher in four patients ventilated for neurological conditions without lung disease. Three maternal and three neonatal deaths occurred. Ten patients delivered while on ventilatory support: one spontaneous delivery, four for obstetric indications and five for worsening maternal condition. Following delivery of these 10 patients, three demonstrated a greater than 50% decrease in oxygenation index and five a greater than 50% increase in compliance. No characteristics identified which patients may benefit from delivery.

CONCLUSIONS

Review of current practice in four centers suggests that mechanical ventilation in pregnant patients follows usual guidelines applicable to non-pregnant patients. Delivery was associated with modest improvement in maternal respiratory function in some patients. Any potential benefit of delivery in improving maternal physiology must be weighed against the stress of delivery. The risks of premature birth for the fetus must be weighed against continued exposure to maternal hypoxemia and hypotension.

Treatment goals: health care improvement through setting and measuring patient-centred outcomes

OBJECTIVE

To determine how frequently stress ulcer prophylaxis (SUP) medications prescribed in the intensive care unit are inappropriately continued on the ward and on hospital discharge.

DESIGN

Retrospective cohort study; chart review.

SETTING

Two Australian ICUs: one tertiary centre and one metropolitan centre.

PARTICIPANTS

We included 387 adult, non-pregnant patients who were admitted to the ICU between 1 February 2011 and 31 March 2011 and who survived to hospital discharge.

MAIN OUTCOME MEASURES

Rate of unnecessary continuation of ICU-prescribed SUP medications on the ward and on discharge from hospital.

RESULTS

While in the ICU, 329 of the 387 patients (85%) were prescribed SUP medications. Of the 233 patients who had not been taking acid-suppressive medications before admission to the ICU, 190 were prescribed SUP medications in the ICU. Of these 190 patients, most (63%) had their SUP continued in the ward without any obvious indication, and many (39%) had their SUP medications inappropriately continued on discharge from hospital.

CONCLUSIONS

SUP medications commenced in ICU are frequently continued unnecessarily, both in the wards and on hospital discharge.

Inappropriate continuation of stress ulcer prophylaxis beyond the intensive care setting

OBJECTIVE

To determine how frequently stress ulcer prophylaxis (SUP) medications prescribed in the intensive care unit are inappropriately continued on the ward and on hospital discharge.

DESIGN

Retrospective cohort study; chart review.

SETTING

Two Australian ICUs: one tertiary centre and one metropolitan centre.

PARTICIPANTS

We included 387 adult, non-pregnant patients who were admitted to the ICU between 1 February 2011 and 31 March 2011 and who survived to hospital discharge.

MAIN OUTCOME MEASURES

Rate of unnecessary continuation of ICU-prescribed SUP medications on the ward and on discharge from hospital.

RESULTS

While in the ICU, 329 of the 387 patients (85%) were prescribed SUP medications. Of the 233 patients who had not been taking acid-suppressive medications before admission to the ICU, 190 were prescribed SUP medications in the ICU. Of these 190 patients, most (63%) had their SUP continued in the ward without any obvious indication, and many (39%) had their SUP medications inappropriately continued on discharge from hospital.

CONCLUSIONS

SUP medications commenced in ICU are frequently continued unnecessarily, both in the wards and hospital discharge.

Obstetric admissions to an integrated general intensive care unit in a quaternary maternity facility

BACKGROUND

Monash Medical Centre (MMC) is a university-affiliated tertiary referral hospital in Melbourne, Victoria, Australia. The hospital has a large obstetric service and is the only quarternary obstetric unit in Victoria. The intensive care unit (ICU) is a busy 21-bed general unit with a broad casemix. While there is no designated state service obstetric ICU in Victoria, MMC ICU has increasingly tried to accept all obstetric patients referred, from both MMC and externally.

AIM

To provide a local perspective on obstetric intensive care in Australia.

METHODS

A retrospective audit of obstetric ICU admissions over 2 years.

RESULTS

Sixty women were admitted, of whom 46 were postpartum. Twenty-nine women were transferred from external sites. Mean maternal age was 30.7 years, mean gestational age 34.5 weeks and mean Acute Physiology and Chronic Health Evaluation (APACHE) version IIIj score 33. Obstetric haemorrhage was the most common admission diagnosis, followed by hypertensive spectrum disorders. Three women were admitted for induction of labour. Median length of stay was 35 h. Twenty-seven women (45%) required mechanical ventilation. No woman died in the ICU, although one died in hospital post-ICU discharge. No data were collected on neonatal outcomes.

CONCLUSIONS

Critically ill obstetric patients can be managed successfully in a general ICU with obstetric input. It may be sensible to cluster these patients into units that are best equipped to deal with them, especially in the ante- and peripartum period.