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Various electrocardiographic changes occur during sepsis, but data on the clinical importance of a low QRS voltage in sepsis are still limited. We aimed to evaluate the association between low QRS voltage identified early in sepsis and mortality in patients with sepsis. Between September 2019 and December 2020, all consecutive adult patients diagnosed with sepsis in the emergency room or general ward at Samsung Medical Center were enrolled. Patients without a 12-lead electrocardiogram recorded within 48 h of recognition of sepsis were excluded. In 432 eligible patients, 12-lead electrocardiogram was recorded within the median of 24 min from the first recognition of sepsis, and low QRS voltage was identified in 115 (26.6%) patients. The low QRS group showed more severe organ dysfunction and had higher levels of N-terminal pro-brain natriuretic peptide. The hospital mortality was significantly higher in the low QRS voltage group than in the normal QRS voltage group (49.6% vs. 28.1%, p < 0.001). Similarly, among the 160 patients who required intensive care unit admission, significantly more patients in the low QRS group died in the intensive care unit (35.9% vs. 18.2%, p = 0.021). Low QRS voltage was associated with increased hospital mortality in patients with sepsis. [ABSTRACT FROM AUTHOR]

Background Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities. Objective To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols. Design Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023. Setting Cross-sectional online survey including hospitals, rehabilitation and long-term facilities. Methods Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers. Results Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n  = 1110) of wards/units, 18.6% (n  = 310) used personal judgement or no assessment, and 10% (n  = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n  = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [ n  = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289–9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions. Conclusion Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium. [ABSTRACT FROM AUTHOR]

This study determined whether compared to conventional mechanical ventilation (MV), extracorporeal membrane oxygenation (ECMO) is associated with decreased hospital mortality or fibrotic changes in patients with COVID-19 acute respiratory distress syndrome. A cohort of 72 patients treated with ECMO and 390 with conventional MV were analyzed (February 2020–December 2021). A target trial was emulated comparing the treatment strategies of initiating ECMO vs no ECMO within 7 days of MV in patients with a PaO2/FiO2 < 80 or a PaCO2 ≥ 60 mmHg. A total of 222 patients met the eligibility criteria for the emulated trial, among whom 42 initiated ECMO. ECMO was associated with a lower risk of hospital mortality (hazard ratio [HR], 0.56; 95% confidence interval [CI] 0.36–0.96). The risk was lower in patients who were younger (age < 70 years), had less comorbidities (Charlson comorbidity index < 2), underwent prone positioning before ECMO, and had driving pressures ≥ 15 cmH2O at inclusion. Furthermore, ECMO was associated with a lower risk of fibrotic changes (HR, 0.30; 95% CI 0.11–0.70). However, the finding was limited due to relatively small number of patients and differences in observability between the ECMO and conventional MV groups. [ABSTRACT FROM AUTHOR]

Background/Aims: The massive transfusion protocol (MTP) can improve the outcomes of trauma patients with hemorrhagic shock and some patients with non-traumatic hemorrhagic shock. However, no information is available regarding whether MTP can improve the outcomes of acute variceal bleeding (AVB). This study aimed to determine the effects of MTP on the outcomes of patients with AVB. Methods: Consecutive patients (n = 218) with AVB who did not have current malignancy and visited the emergency room between July 2014 and June 2022 were analyzed. 42-day mortality and failure to control the bleeding were compared between patients with and without MTP activation. Additionally, propensity-score matching was conducted. Results: The amount of blood product transfused was higher in the MTP group. The 42-day mortality rate (42.1% vs. 1.5%, p < 0.001) and the rate of failure to control bleeding (36.8% vs. 0.5%, p < 0.001) were significantly higher in those who received blood transfusions by MTP. MTP was an independent factor associated with 42-day mortality in the multivariable-adjusted analysis (HR 21.05; 95% CI 3.07–144.21, p = 0.002, HR 24.04; 95% CI 3.41–169.31, p = 0.001). The MTP group showed consistently higher 42-day mortality and failure to control bleeding in all subgroup analyses, stratified by systolic blood pressure, hemoglobin level, and the model for end-stage liver disease score. The MTP group also showed higher 42-day mortality (42.9% vs. 0%, p = 0.001) and failure to control bleeding (42.9% vs. 0%, p = 0.001) in a propensity score-matched analysis (n = 52). Conclusions: MTP was associated with poor outcomes in patients with AVB. Further studies are needed to see whether MTP can be an option for patients with massive AVB. [ABSTRACT FROM AUTHOR]

Background: Only some studies have directly compared and analyzed the roles of activated partial thromboplastin time (aPTT) and activated clotting time (ACT) in coagulation monitoring during argatroban administration. Objectives: This study aims to assess the correlation of argatroban dose with ACT and aPTT values and to identify the optimal coagulation test for argatroban dose adjustment. Methods: We evaluated 55 patients on extracorporeal membrane oxygenation (ECMO) who received argatroban for more than 72 hours. The correlation between argatroban dose and aPTT and ACT values was evaluated. To compare argatroban dose and bleeding events according to liver dysfunction, the patients were divided into 2 groups based on alanine aminotransferase and total bilirubin. Results: Among the 55 patients, a total of 459 doses and coagulation tests were evaluated. The aPTT and ACT values showed a weak correlation with argatroban dose, with the Pearson correlation coefficients of 0.261 (P < 0.001) and 0.194 (P = 0.001), respectively. The agreement between the target 150 to 180 seconds for ACT and 55 to 75 seconds for aPTT was observed in 140 patients (46.1%). Twenty-four patients (43.6%) had liver dysfunction when they started argatroban. The median argatroban dose was lower in the liver dysfunction group than in the control group (0.094 mcg/kg/min vs 0.169 mcg/kg/min, P = 0.020). Difference was not observed between the 2 groups in the amount of red blood cell (0.47 vs 0.43 pack, P = 0.909) and platelet (0.60 vs 0.08 pack, P = 0.079) transfusion per day. Conclusion and Relevance: A weak correlation was observed between argatroban dose and the aPTT and ACT values. However, the agreement between aPTT and ACT was only 46.1% regarding the scope of target range. Further research is necessary to determine how to assess the optimal argatroban dose for patients administered argatroban while undergoing ECMO at the intensive care unit. [ABSTRACT FROM AUTHOR]

This retrospective cohort study aimed to evaluate the association between ambulatory status at discharge and six-month post-discharge mortality among adults with coronavirus disease (COVID-19). We analyzed data from 398 patients aged over 18 admitted to a tertiary hospital in South Korea between December 2019 and June 2022. Patients were classified into two groups based on their ambulatory status at discharge: ambulatory (able to walk independently, n = 286) and non-ambulatory (unable to walk independently, requiring wheelchair or bed-bound, n = 112). Our analysis revealed that six-month survival rates were significantly higher in the ambulatory group (94.2%) compared to the non-ambulatory group (84.4%). Multivariate analysis identified ambulatory status at discharge (p = 0.047) and pre-existing malignancy (p = 0.007) as significant prognostic factors for post-discharge survival. This study highlights that the ability to walk independently at discharge is a crucial predictor of six-month survival in COVID-19 patients. These findings emphasize the need for interventions to improve the physical performance of non-ambulatory patients, potentially enhancing their survival prospects. This underscores the importance of targeted rehabilitation and physical therapy for the comprehensive care of COVID-19 survivors. [ABSTRACT FROM AUTHOR]

Pulmonary artery catheterization (PAC) has been used as a clinical standard for cardiac output (CO) measurements on humans. On animals, however, an ultrasonic flow sensor (UFS) placed around the ascending aorta or pulmonary artery can measure CO and stroke volume (SV) more accurately. The objective of this paper is to compare CO and SV measurements using a noninvasive electrical impedance tomography (EIT) device and three invasive devices using UFS, PAC-CCO (continuous CO) and arterial pressure-based CO (APCO). Thirty-two pigs were anesthetized and mechanically ventilated. A UFS was placed around the pulmonary artery through thoracotomy in 11 of them, while the EIT, PAC-CCO and APCO devices were used on all of them. Afterload and contractility were changed pharmacologically, while preload was changed through bleeding and injection of fluid or blood. Twenty-three pigs completed the experiment. Among 23, the UFS was used on 7 pigs around the pulmonary artery. The percentage error (PE) between COUFS and COEIT was 26.1%, and the 10-min concordance was 92.5%. Between SVUFS and SVEIT, the PE was 24.8%, and the 10-min concordance was 94.2%. On analyzing the data from all 23 pigs, the PE between time-delay-adjusted COPAC-CCO and COEIT was 34.6%, and the 10-min concordance was 81.1%. Our results suggest that the performance of the EIT device in measuring dynamic changes of CO and SV on mechanically-ventilated pigs under different cardiac preload, afterload and contractility conditions is at least comparable to that of the PAC-CCO device. Clinical studies are needed to evaluate the utility of the EIT device as a noninvasive hemodynamic monitoring tool. [ABSTRACT FROM AUTHOR]

Simple Summary: This study aimed to develop a new warning score for cancer patients who are at risk of getting worse in the hospital. Cancer patients can have serious problems due to their treatment or cancer itself. A quick response system is used to find and treat these patients. This study used a deep-learning method to create a warning score based on the changes in vital signs. The warning score, called Can-EWS, was better than the existing score, called MEWS, in predicting and preventing bad outcomes. Can-EWS also had fewer false alarms than MEWS. This study could help improve the safety and care of cancer patients in the hospital. Background: Cancer patients who are admitted to hospitals are at high risk of short-term deterioration due to treatment-related or cancer-specific complications. A rapid response system (RRS) is initiated when patients who are deteriorating or at risk of deteriorating are identified. This study was conducted to develop a deep learning-based early warning score (EWS) for cancer patients (Can-EWS) using delta values in vital signs. Methods: A retrospective cohort study was conducted on all oncology patients who were admitted to the general ward between 2016 and 2020. The data were divided into a training set (January 2016–December 2019) and a held-out test set (January 2020–December 2020). The primary outcome was clinical deterioration, defined as the composite of in-hospital cardiac arrest (IHCA) and unexpected intensive care unit (ICU) transfer. Results: During the study period, 19,739 cancer patients were admitted to the general wards and eligible for this study. Clinical deterioration occurred in 894 cases. IHCA and unexpected ICU transfer prevalence was 1.77 per 1000 admissions and 43.45 per 1000 admissions, respectively. We developed two models: Can-EWS V1, which used input vectors of the original five input variables, and Can-EWS V2, which used input vectors of 10 variables (including an additional five delta variables). The cross-validation performance of the clinical deterioration for Can-EWS V2 (AUROC, 0.946; 95% confidence interval [CI], 0.943–0.948) was higher than that for MEWS of 5 (AUROC, 0.589; 95% CI, 0.587–0.560; p < 0.001) and Can-EWS V1 (AUROC, 0.927; 95% CI, 0.924–0.931). As a virtual prognostic study, additional validation was performed on held-out test data. The AUROC and 95% CI were 0.588 (95% CI, 0.588–0.589), 0.890 (95% CI, 0.888–0.891), and 0.898 (95% CI, 0.897–0.899), for MEWS of 5, Can-EWS V1, and the deployed model Can-EWS V2, respectively. Can-EWS V2 outperformed other approaches for specificities, positive predictive values, negative predictive values, and the number of false alarms per day at the same sensitivity level on the held-out test data. Conclusions: We have developed and validated a deep learning-based EWS for cancer patients using the original values and differences between consecutive measurements of basic vital signs. The Can-EWS has acceptable discriminatory power and sensitivity, with extremely decreased false alarms compared with MEWS. [ABSTRACT FROM AUTHOR]

The article discusses the challenges faced by patients undergoing extracorporeal membrane oxygenation (ECMO) in the intensive care unit (ICU) and the importance of evidence-based and supportive care in improving patient outcomes. The authors conducted a secondary analysis of previous studies and found that the implementation of the recommended 'ABCDEF' bundle, which includes pain assessments, sedation assessments, delirium assessments, spontaneous awakening trials, early mobility and exercise, and family engagement and empowerment, was extremely low for ECMO patients. Additionally, nutrition therapy was not adequately provided to these patients. The study highlights the need for improved ICU care for ECMO patients to enhance their functional outcomes. [Extracted from the article]

The optimal timing of enteral nutrition (EN) in sepsis patients is controversial among societal guidelines. We aimed to evaluate the evidence of early EN's impact on critically ill sepsis patients' clinical outcomes. We searched the MEDLINE, Embase, CINAHL, Cochrane Library, ClinicalTrials.gov, and ICTRP databases on 10 March 2023. We included studies published after 2004 that compared early EN versus delayed EN in sepsis patients. We included randomized controlled trials (RCTs), non-RCTs, cohort studies, and case–control studies. Forest plots were used to summarize risk ratios (RRs), including mortality and mean difference (MD) of continuous variables such as intensive care unit (ICU) length of stay and ventilator-free days. We identified 11 eligible studies with sample sizes ranging from 31 to 2410. The RR of short-term mortality from three RCTs was insignificant, and the MD of ICU length of stay from two RCTs was −2.91 and −1.00 days (95% confidence interval [CI], −5.53 to −0.29 and −1.68 to −0.32). Although the RR of intestinal-related complications from one RCT was 3.82 (95% CI, 1.43 to 10.19), indicating a significantly higher risk for the early EN group than the control group, intestinal-related complications of EN reported in five studies were inconclusive. This systematic review did not find significant benefits of early EN on mortality in sepsis patients. Evidence, however, is weak due to inconsistent definitions, heterogeneity, risk of bias, and poor methodology in the existing studies. [ABSTRACT FROM AUTHOR]

Background: Numerous epidemiological studies investigating gender-dependent clinical outcomes in sepsis have shown conflicting evidence. This study aimed to investigate the effect of gender on in-hospital mortality due to sepsis according to age group. Methods: This study used data from the Korean Sepsis Alliance, an ongoing nationwide prospective multicenter cohort from 19 participating hospitals in South Korea. All adult patients diagnosed with sepsis in the emergency departments of the participating hospitals between September 2019 and December 2021 were included in the analysis. Clinical characteristics and outcomes were compared between male and female. Eligible patients were stratified by age into 19–50 years, 50–80 years, and ≥ 80 years old individuals. Results: During the study period, 6442 patients were included in the analysis, and 3650 (56.7%) were male. The adjusted odds ratio (OR) [95% confidence interval (CI)] for in-hospital mortality for male compared with female was 1.15 (95% CI = 1.02–1.29). Interestingly, in the age 19–50 group, the risk of in-hospital mortality for males was significantly lower than that of females [0.57 (95% CI = 0.35–0.93)]. For female, the risk of death remained relatively stable until around age 80 (P for linearity = 0.77), while in males, there was a linear increase in the risk of in-hospital death until around age 80 (P for linearity < 0.01). Respiratory infection (53.8% vs. 37.4%, p < 0.01) was more common in male, whereas urinary tract infection (14.7% vs. 29.8%, p < 0.01) was more common in female. For respiratory infection, male had significantly lower in-hospital mortality than female in the age 19–50 groups (adjusted OR = 0.29, 95% CI = 0.12–0.69). Conclusions: Gender may influence age-associated sepsis outcomes. Further studies are needed to replicate our findings and fully understand the interaction of gender and age on the outcomes of patients with sepsis. [ABSTRACT FROM AUTHOR]

Continuous monitoring of both hemodynamic and respiratory parameters would be beneficial to patients, e.g., those in intensive care unit. The objective of this exploratory animal study was to test the feasibility of simultaneous measurements of relative tidal volume (rTV) and relative stroke volume (rSV) using an electrical impedance tomography (EIT) device equipped with a new real-time source separation algorithm implemented as two spatial filters. Five pigs were anesthetized and mechanically ventilated. The supplied tidal volume from a mechanical ventilator was reduced to 70, 50 and 30% from the 100% normal volume to simulate hypoventilation. The respiratory volume signal and cardiac volume signal were generated by applying the spatial filters to the acquired EIT data, from which values of rTV and rSV were extracted. The measured rTV values were compared with the TV values from the mechanical ventilator using the four-quadrant concordance analysis method. For changes in TV, the concordance rate in each animal ranged from 81.8% to 100%, while it was 92.5% when the data from all five animals were pooled together. When the measured rTV values for each animal were scaled to the absolute TVEIT values in mL using the TVVent data from the mechanical ventilator, the smallest 95% limits of agreement (LoA) were − 6.04 and 7.44 mL for the 70% ventilation level, and the largest 95% LoA were − 18.1 and 19.4 mL for the 50% ventilation level. The percentage error between TVEIT and TVVent was 10.3%. Although similar statistical analyses on rSV data could not be performed due to limited intra-animal variability, changes in rSV values measured by the EIT device were comparable to those measured by an invasive hemodynamic monitor. In this animal study, we were able to demonstrate the feasibility of an EIT device for noninvasive and simultaneous measurements of rTV and rSV in real time. However, the performance of the real-time source separation method needs to be further validated on animals and human subjects, particularly over a wide range of SV values. Future clinical studies are needed to assess the potential usefulness of the new method in dynamic cardiopulmonary monitoring and explore other clinical applications. [ABSTRACT FROM AUTHOR]

The Functional Status Score for the Intensive Care Unit (FSS-ICU) evaluates the physical function of ICU patients. The objective of the study was to translate and cross-culturally adapt the FSS-ICU into Korean and assess its reliability and validity. An expert committee supervised the forward and backward translation process and the final translated version. Experienced physiotherapists assessed patients (n= 31) from a medical ICU using the Korean version of FSS-ICU. Intra-class correlation coefficients (ICCs) and Bland–Altman's plots were used to evaluate reliability, and Cronbach's alpha for internal consistency. Construct validity was evaluated using Spearman's correlation coefficients. Two physiotherapists in each of the two university hospitals independently assessed 31 medical ICU patients, with a mean FSS-ICU total score of 23 (range: 4–35). The FSS-ICU Korean version demonstrated excellent internal consistency, with Cronbach's alpha of 0.897 for the total FSS-ICU score, and a range of 0.844–0.892 with deletion of each individual activity within the FSS-ICU. Intra-rater and inter-rater reliability were excellent for all of five FSS-ICU activities and the total score, with an ICC range of 0.930–0.993. Bland–Altman's plots revealed a mean difference in FSS-ICU total score of 0.2 (95% limits of agreement: −1.9 to 2.3) between two physiotherapists. The Korean version of FSS-ICU had good convergent and divergent validity with moderate to strong correlation with mobility and muscle strength measures, and poor correlation with unrelated measures. The Korean version of the FSS-ICU showed excellent intra-rater and inter-rater reliability, internal consistency, and construct validity for medical ICU patients. The results of this study, along with prior publications, support that the FSS-ICU Korean version is a valid and reliable assessment tool for the ICU environment. Intensive care unit patients usually experience decreased muscle strength and physical function. The Korean version of the Functional Status Score for the Intensive Care Unit (FSS-ICU) is suitable for use with Korean speakers and has a valid, reliable measurement tool for physical function of intensive care unit patients. A well-standardized training with videos and written materials is important to ensure correct implementation of the Korean version of the FSS-ICU. [ABSTRACT FROM AUTHOR]

Background: Only a few observational studies using small patient samples and one subgroup analysis have compared norepinephrine and dopamine for the treatment of cardiogenic shock (CS). The objective of the present study was to investigate whether the use of norepinephrine was associated with improvements in clinical outcomes in CS patients compared to dopamine. Methods: We retrospectively reviewed hospital medical records of patients who were admitted to cardiac intensive care unit from 2012 to 2018. We included 520 patients with CS in this analysis. The primary outcome was in-hospital mortality, and serial hemodynamic data were also assessed. Results: As a first-line vasopressor, dopamine was used in 156 patients (30%) and norepinephrine in 364 patients (70%). Overall, the norepinephrine group had significantly higher severity of shock, arrest at presentation, vital signs, and lactic acid than did the dopamine group at the time of vasopressor initiation. Nevertheless, in the norepinephrine group, additional vasopressor was required in 123 patients (33.8%), which was a significantly smaller percentage than the 92 patients (56.4%) in the dopamine group who required additional vasopressor (p < 0.001). There was no significant difference in in-hospital mortality between the two groups (26.9% and 31.9%, respectively, p = 0.26). In addition, the incidence of arrhythmia was not different between the two groups (atrial fibrillation, 12.2% vs. 15.7%, p = 0.30; ventricular tachyarrhythmia, 19.9% vs. 25.3%, p = 0.18). Conclusions: The use of norepinephrine as a first-line vasopressor was not associated with reductions of in-hospital mortality or arrythmia but could reduce use of additional vasopressors in CS patients. [ABSTRACT FROM AUTHOR]

Purpose: To assess the effect of continuous ketamine administration in patients admitted to medical and cardiac intensive care units (ICUs) and received mechanical ventilation support. Methods: We conducted a retrospective cohort study between March 2012 and June 2020 at an academy-affiliated tertiary hospital. Adult patients who received mechanical ventilation support for over 24 h and continuous ketamine infusion for at least 8 h were included. The primary outcome was immediate hemodynamic safety after continuous ketamine infusion. The secondary outcomes included immediate delirium, pain, and use of sedation. Results: Of all 12,534 medical and cardiac ICU patients, 564 were eligible for the analysis. Ketamine was used for 33.3 (19.0–67.5) h and the median continuous infusion dose was 0.11 (0.06–0.23) mcg/kg/h. Of all patients, 469 (83.2%) received continuous ketamine infusion concomitant with analgosedation. Blood pressure and vasopressor inotropic scores did not change after continuous ketamine infusion. Heart rate decreased significantly from 106.9 (91.4–120.9) at 8 h before ketamine initiation to 99.8% (83.9–114.4) at 24 h after ketamine initiation. In addition, the respiratory rate decreased from 21.7 (18.6–25.4) at 8 h before ketamine initiation to 20.1 (17.0–23.0) at 24 h after ketamine initiation. Overall opioid usage was significantly reduced: 3.0 (0.0–6.0) mcg/kg/h as fentanyl equivalent dose at 8 h before ketamine initiation to 1.0 (0.0–4.1) mcg/kg/h as fentanyl equivalent dose at 24 h post-ketamine initiation. However, the use of sedatives and antipsychotic medications did not decrease. In addition, ketamine did not increase the incidence of delirium within 24 h after ketamine infusion. Conclusion: Ketamine may be a safe and feasible analgesic for medical and cardiac ICU patients who received mechanical ventilation support as an opioid-sparing agent without adverse hemodynamic effects. [ABSTRACT FROM AUTHOR]

Background: Limited data are available on clinical phenotype for delirium that occurs frequently among patients admitted to the cardiac intensive care unit (CICU). The objective of this study was to investigate the clinical pictures of delirium, and their association with clinical outcomes in CICU patients. Methods: A total of 4,261 patients who were admitted to the CICU between September 1 2012 to December 31 2018 were retrospectively registered. Patients were excluded if they were admitted to the CICU for less than 24 hours or had missed data. Ultimately, 2,783 patients were included in the analysis. A day of delirium was defined as any day during which at least one CAM-ICU assessment was positive. The clinical risk factors of delirium were classified by the delirium phenotype, as follows; hypoxic, septic, sedative-associated, and metabolic delirium. Results: The incidence of delirium was 24.4% at the index hospitalization in all CICU patients, and 22.6% within 7 days after CICU admission. The most common delirium phenotype was septic delirium (17.2%), followed by hypoxic delirium (16.8%). Multiple phenotypes were observed during most delirium days. Delirium most frequently occurred in patients with heart failure. Of all patients affected by delirium within 7 days, both ICU and hospital mortality significantly increased according to the combined number of delirium phenotypes. Conclusions: Delirium occurred in a quarter of patients admitted to the modern CICU and was associated with increased in-hospital mortality. Therefore, more efforts are needed to reduce the clinical risk factors of delirium, and to prevent it in order to improve clinical outcomes in the CICU. [ABSTRACT FROM AUTHOR]

For the clinical application of semi-quantitative anti-SARS-CoV-2 antibody tests, the analytical performance and titer correlation of the plaque reduction neutralization test (PRNT) need to be investigated. We evaluated the analytical performance and PRNT titer-correlation of one surrogate virus neutralization test (sVNT) kit and three chemiluminescent assays. We measured the total antibodies for the receptor-binding domain (RBD) of the spike protein, total antibodies for the nucleocapsid protein (NP), and IgG antibodies for the RBD. All three chemiluminescent assays showed high analytical performance for the detection of SARS-CoV-2 infection, with a sensitivity ≥ 98% and specificity ≥ 99%; those of the sVNT were slightly lower. The representativeness of the neutralizing activity of PRNT ND50 ≥ 20 was comparable among the four immunoassays (Cohen's kappa ≈ 0.80). Quantitative titer correlation for high PRNT titers of ND50 ≥ 50, 200, and 1,000 was investigated with new cut-off values; the anti-RBD IgG antibody kit showed the best performance. It also showed the best linear correlation with PRNT titer in both the acute and convalescent phases (Pearson's R 0.81 and 0.72, respectively). Due to the slowly waning titer of anti-NP antibodies, the correlation with PRNT titer at the convalescent phase was poor. In conclusion, semi-quantitative immunoassay kits targeting the RBD showed neutralizing activity that was correlated by titer; measurement of anti-NP antibodies would be useful for determining past infections. [ABSTRACT FROM AUTHOR]

Purpose: Intensive care unit (ICU) survivors suffer from physical weakness and challenges returning to daily life. With the importance of rehabilitating patients in the pediatric intensive care unit being increasingly recognized, we evaluated the prevalence of physical and occupational therapy (PT/OT)-provided rehabilitation and factors affecting its use. Methods: We conducted a retrospective cohort analysis of rehabilitation between 2013 and 2019 using the Korean National Health Insurance database. All patients aged 28 days to 18 years who had been admitted to 245 ICUs for more than 2 days were included. Neonatal ICUs were excluded. Results: Of 13,276 patients, 2,447 (18%) received PT/OT-provided rehabilitation during their hospitalization; prevalence was lowest for patients younger than 3 years (11%). Neurologic patients were most likely to receive rehabilitation (adjusted odds ratio [aOR], 6.47; 95% confidence interval [CI], 5.11–8.20). Longer ICU stay (versus ≤ 1 week) was associated with rehabilitation (aOR for 1–2 weeks, 3.50 [95% CI, 3.04–4.03]; 2–3 weeks, 6.60 [95% CI, 5.45–8.00]; >3 weeks, 13.69 [95% CI, 11.46–16.35]). Mechanical ventilation >2 days (aOR, 0.78; 95% CI, 0.67–0.91) and hemodialysis (aOR, 0.50; 95% CI, 0.41–0.52) were negatively affecting factors. Conclusion: Prevalence of rehabilitation for critically ill children was low and concentrated on patients with a prolonged ICU stay. The finding that mechanical ventilation, a risk factor for ICU-acquired weakness, was an obstacle to rehabilitation highlights the need for studies on early preventive rehabilitation based on individual patient needs. [ABSTRACT FROM AUTHOR]

Objective: Delirium in the intensive care unit (ICU) may be a preventable risk factor for cognitive impairment or psychiatric problems. We aimed to evaluate the association between the presence of delirium during hospitalization involving ICU care and post-discharge cognitive impairment or psychiatric problems. Design: A retrospective cohort study. Setting: A database of nationwide insurance claims data. Patients: All adult patients aged 18 years or older who were admitted to an ICU between January 1, 2008, and May 31, 2015, and had no history of previous cognitive impairment or psychiatric problems were included in the study. Interventions: None. Measurements and main results: Of 306,011 patients who met the inclusion criteria, the proportion of those who experienced delirium during hospitalization was 55.0% (n = 168,190). The patients with delirium during hospitalization had significantly increased odds for cognitive impairment (adjusted hazard ratio [HR] 1.17; 95% confidence interval [CI] 1.05–1.29) and psychiatric problems (adjusted HR 1.78; 95% CI 1.67–1.90) after discharge compared with patients without delirium. In patients who had delirium, the incidence of cognitive impairment was 210.8 per 1000 person-years. In 19,496 patients who were diagnosed with cognitive impairment, depression (n = 3233, 16.5%), sleep disorder (n = 1791, 9.2%), and anxiety (n = 1683, 8.6%) were commonly co-diagnosed. The most common psychiatric problem was sleep disorder (148.7 per 1000 person-years), followed by depression (133.3 per 1000 person-years). Conclusions: Among patients received ICU care, those who experienced delirium during hospitalization had an increased risk of developing cognitive impairment or psychiatric problems post-discharge. Many patients showed multiple cognitive impairment and psychiatric problems during the follow-up period. Efforts to decrease these problems should be made to increase the quality of life of these ICU survivors. [ABSTRACT FROM AUTHOR]

Background: Timely administration of antibiotics is one of the most important interventions in reducing mortality in sepsis. However, administering antibiotics within a strict time threshold in all patients suspected with sepsis will require huge amount of effort and resources and may increase the risk of unintentional exposure to broad-spectrum antibiotics in patients without infection with its consequences. Thus, controversy still exists on whether clinicians should target different time-to-antibiotics thresholds for patients with sepsis versus septic shock.Methods: This study analyzed prospectively collected data from an ongoing multicenter cohort of patients with sepsis identified in the emergency department. Adjusted odds ratios (ORs) were compared for in-hospital mortality of patients who had received antibiotics within 1 h to that of those who did not. Spline regression models were used to assess the association of time-to-antibiotics as continuous variables and increasing risk of in-hospital mortality. The differences in the association between time-to-antibiotics and in-hospital mortality were assessed according to the presence of septic shock.Results: Overall, 3035 patients were included in the analysis. Among them, 601 (19.8%) presented with septic shock, and 774 (25.5%) died. The adjusted OR for in-hospital mortality of patients whose time-to-antibiotics was within 1 h was 0.78 (95% confidence interval [CI] 0.61-0.99; p = 0.046). The adjusted OR for in-hospital mortality was 0.66 (95% CI 0.44-0.99; p = 0.049) and statistically significant in patients with septic shock, whereas it was 0.85 (95% CI 0.64-1.15; p = 0.300) in patients with sepsis but without shock. Among patients who received antibiotics within 3 h, those with septic shock showed 35% (p = 0.042) increased risk of mortality for every 1-h delay in antibiotics, but no such trend was observed in patients without shock.Conclusion: Timely administration of antibiotics improved outcomes in patients with septic shock; however, the association between early antibiotic administration and outcome was not as clear in patients with sepsis without shock. [ABSTRACT FROM AUTHOR]

Background: Continuous renal replacement therapy (CRRT) is the standard treatment for severe acute kidney injury in critically ill patients. However, a practical consensus for discontinuing CRRT is lacking. We aimed to develop a prediction model with simple clinical parameters for successful discontinuation of CRRT. Methods: Adult patients who received CRRT at Samsung Medical Center from 2007 to 2017 were included. Patients with preexisting ESRD and patients who progressed to ESRD within 1 year or died within 7 days after CRRT were excluded. Successful discontinuation of CRRT was defined as no requirement for renal replacement therapy for 7 days after discontinuing CRRT. Patients were assigned to either a success group or failure group according to whether discontinuation of CRRT was successful or not. Results: A total of 1,158 patients were included in the final analyses. The success group showed greater urine output on the day before CRRT discontinuation (D-1) and the discontinuation day (D0). Multivariable analysis identified that urine output ≥300 mL on D-1, and mean arterial pressure 50∼78 mm Hg, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 were predictive factors for successful discontinuation of CRRT. A scoring system using the 4 variables above (area under the receiver operating curve: 0.731) was developed. Conclusions: Scoring system composed of urine output ≥300 mL/day on D-1, and adequate blood pressure, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 was developed to predict successful discontinuation of CRRT. [ABSTRACT FROM AUTHOR]

Background: There is a lack of nationwide studies on critically ill patients' health disparity under the National Health Insurance (NHI) system. We evaluated health disparities in intensive care unit (ICU) admission, outcomes, and readmission in impoverished children.Methods: We conducted a retrospective cohort study using a national database from the Korean NHI and Medical Aid Program (MAP). MAP supports the population whose household income is lower than 40% of the median Korean household income. We defined poverty as being a MAP beneficiary and compared the poverty and non-poverty groups. Patients between 28 days and 18 years old who were admitted to the ICU were included. Hospital mortality and readmission were analyzed with adjustment for patient characteristics, hospital type, and management procedures.Results: Out of 17,893 patients, 1153 (6.4%) patients were in poverty. The age-standardized ICU admission rate was higher in the poverty group (126.9 vs. 80.2 per 100,000 person-years). There was more age-standardized mortality in the poverty group (11.8 vs. 4.3 per 100,000 person-years). Patients in the poverty group did not have a statistically different risk of adjusted in-hospital mortality to those in the non-poverty group (odds ratio: 1.15, confidence interval [CI]: 0.84-1.55) but had a higher readmission rate (hazard ratio 1.25, CI 1.09-1.42).Conclusion: Under the NHI system, the disparity in pediatric critical care outcomes according to poverty is not definite, but the healthcare disparity in pre- and post-hospital care is a concern. Further studies are required to improve pre- and post-hospital healthcare quality of impoverished children. [ABSTRACT FROM AUTHOR]

Although extracorporeal membrane oxygenation (ECMO) is increasingly utilized, only a limited level of experience has been reported in postpartum cardiopulmonary failure. Ten critically ill postpartum patients who received ECMO were included between January 2010 and December 2018 in this retrospective observational study. The main indication for ECMO support was peripartum cardiomyopathy (n = 5), followed by postpartum hemorrhage (n = 2). Nine patients initially received veno-arterial ECMO, and one patient received veno-venous ECMO. Major bleeding occurred in six patients. The median number of units of red blood cells (RBC) transfused during ECMO was 14.5 units (interquartile range 6.8–37.8 units), and most RBC transfusions occurred on the first day of ECMO. The survival-to-discharge rate was 80%. Compared to the survival outcomes in female patients of similar age who received ECMO, the survival outcomes were significantly better in the study population (56% versus 80%, P = 0.0004). Despite the high risk of major bleeding, ECMO for patients with postpartum cardiac or respiratory failure showed excellent survival outcomes. ECMO is feasible in these patients and can be carried out with good outcomes in an experienced centre. [ABSTRACT FROM AUTHOR]

Background: Frailty is a multidimensional syndrome that leads to an increase in vulnerability. Previous studies have suggested that frailty is associated with poor health-related outcomes. For frailty screening, the Clinical Frailty Scale (CFS) is a simple tool that is widely used in various translated versions. We aimed to translate the CSF into Korean and evaluated its contents and concurrent validity.Methods: Translations and back-translations of the CFS were conducted independently. A multidisciplinary team decided the final CFS-K. Between August 2019 and April 2020, a total of 100 outpatient and inpatient participants aged ≥65 years were enrolled prospectively. The clinical characteristics were evaluated using the CFS-K. The CFS-K scores were compared with those of other frailty screening tools using Pearson's correlation coefficient and Spearman's rank correlation. The area under curve (AUC) for identifying the Eastern Cooperative Oncology Group Performance Status (ECOG PS) grade 3 or more was calculated for the CFS-K and other screening tools.Results: The mean age of the participants was 76.5 years (standard deviation [SD], 7.0), and 63 (63%) participants were male. The mean CFS-K was 4.8 (SD, 2.5). Low body mass index (p = 0.013) and low score on the Korean version of the Mini-Mental State Examination (p < 0.001) were significantly associated with high CFS-K scores, except for those assigned to scale 9 (terminally ill). The CFS-K showed a significant correlation with other frailty screening tools (R = 0.7742-0.9190; p < 0.01), except in the case of those assigned to scale 9 (terminally ill). In comparison with other scales, the CFS-K identified ECOG PS grade 3 or more with the best performance (AUC = 0.99). Patients assigned to scale 9 on the CFS-K (terminally ill) had similar frailty scores to those assigned to scale 4 (vulnerable) or 5 (mildly frail).Conclusions: In conclusion, the CFS-K is a valid scale for measuring frailty in older Korean patients. The CFS-K scores were significantly correlated with the scores of other scales. To evaluate the predictive and prognostic value of this scale, further larger-scale studies in various clinical settings are warranted. [ABSTRACT FROM AUTHOR]

Background: Little is known of nosocomial infections (NI) in patients who suffer from in-hospital cardiac arrest who undergoing extracorporeal cardiopulmonary resuscitation. This study aimed to investigate clinical pictures of NI, and the association of NIs with clinical outcomes in in-hospital cardiac arrest patients who undergoing extracorporeal cardiopulmonary resuscitation. Methods: To evaluate the incidence and clinical characteristics of NI in patients who undergoing extracorporeal cardiopulmonary resuscitation, a retrospective cohort study was conducted in a single tertiary referral center between January 2010 and December 2018. We included adult patients who undergoing extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest and excluded patients who were out-of-hospital cardiac arrest or failed ECMO implantation. Clinical characteristics and outcomes were compared between NI and Non-NI patients, or multidrug-resistant (MDR) and non-MDR. The independent risk factors associated with NIs were also analyzed using multivariable logistic regression model. Results: Thirty-five (23.3%) patients developed a NI. These cases included 21 patients with a gram negative (G-) infection, 12 patients with a gram positive (G+) bacterial infection, and two patients with fungal infection. Pneumonia was the most common type of NIs, followed by catheter-related infection. The in-hospital mortality and neurologic outcomes at discharge were not different between the NI and non-NI groups. Multidrug-resistant (MDR) pathogens were detected in 10 cases (28.6%). The MDR NI patients had a higher ICU mortality than did those with non-MDR NI (80% vs. 32%, p = 0.028). Following multivariable adjustment, body mass index (adjusted OR 0.87, 95% CI, 0.77–0.97, p = 0.016) and cardiopulmonary resuscitation to pump on time (adjusted OR 1.04, 95% CI, 1.01–1.06, p = 0.001) were independent predictors of NI development. Conclusions: In patients who received extracorporeal cardiopulmonary resuscitation, NIs were not associated with an increase in in-hospital mortality. However, NIs with MDR organisms do increase the risk of in-hospital mortality. Lower body mass index and longer low flow time were significant predictors of NI development. [ABSTRACT FROM AUTHOR]

The safety of healthcare workers (HCWs) against severe acute respiratory syndrome virus 2 (SARS-CoV-2) transmission is an important aspect of managing the coronavirus disease 2019 (COVID-19) pandemic. In the South Korea, highly stringent infection prevention and control (IPC) guidelines are implemented, and reports of healthcare-associated SARS-CoV-2 transmission among HCWs are limited. However, subclinical infections may have been missed by the current symptom-based screening strategy. To evaluate the risk of undetected SARS-CoV-2 transmissions from COVID-19 patients to HCWs, we conducted a multicenter seroprevalence study after the first surge of the COVID-19 outbreak. A total of 432 HCWs were evaluated, comprising 309 HCWs designated to laboratory-confirmed COVID-19 patient care and 123 non-designated HCWs. Designated HCWs wore personal protective equipment including an N95 respirator, eye protection, hooded overalls, shoe covers, and inner and outer gloves. Use of a powered air-purifying respirator was recommended for aerosol-generating procedures or long-duration care activities. A high-sensitivity (99.1%) fluorescence immunoassay immunoglobulin G (IgG) kit was used as the initial screening test, and two enzyme-linked immunosorbent assay kits for total and IgG antibodies were used to confirm the test results. A microneutralization test was additionally performed to evaluate the neutralizing activity of positive specimens. Among the evaluated HCWs, none of the non-designated HCWs had a positive result, while one of the HCWs designated for COVID-19 patient care (1/309, 0.3%) was seropositive for SARS-CoV-2 with confirmed neutralizing activity (1:40). This finding suggests that subclinical seroconversion may occur among HCWs caring for COVID-19 patients, although the risk is low under strict IPC guidance. [ABSTRACT FROM AUTHOR]

Secondary hemophagocytic lymphohistiocytosis (HLH) is a rare but fatal condition with various underlying disorders in adult patients and is diagnosed based on the HLH-2004 criteria, which were established based on experience in pediatric patients. However, few studies have prospectively evaluated the treatment outcomes and diagnostic performance of HLH criteria in adult patients with secondary HLH. Thus, we performed a single-center, prospective cohort study of adult patients with suspected HLH, and we analyzed treatment outcomes of patients enrolled between 2017 and 2019 as an interim analysis (ClinicalTrials.gov Identifier: NCT03117010). Of the 73 patients with suspected HLH, 70 patients completed the evaluation for ≥ 7 of the HLH-2004 criteria, and 55 patients were diagnosed with HLH (55/73, 75%). Although serum ferritin and fever had a sensitivity of more than 90%, both had exceptionally low specificity, whereas soluble CD25 had a sensitivity of more than 90% and specificity of 80%. Forty patients with malignancy-associated HLH had B cell (n = 19) or T- or NK-cell (n = 21) lymphoid malignancy, whereas 15 patients had non-malignant disorders. Non-malignancy-associated HLH had greater than 90% 1-year overall survival (OS) after diagnosis of HLH, whereas that for malignancy-associated HLH was less than 40%. In conclusion, our study showed promising treatment outcomes for patients enrolled in our prospective cohort study, and prospectively demonstrated the diagnostic performance of the HLH-2004 criteria in adult patients with suspected HLH. Given that lymphoma was the most common cause of HLH in adults, thorough evaluation for lymphoma should be performed in adults with suspected HLH. [ABSTRACT FROM AUTHOR]

Currently, there is no noninvasive method available for simultaneous measurements of tidal volume and stroke volume. Electrical impedance tomography (EIT) has been used for regional lung ventilation imaging. Cardiac EIT imaging, however, has not been successful due to the technical difficulty in extracting weak cardiogenic components. Instead of regional imaging, in this paper, we use the EIT technique to simultaneously measure two global variables of tidal volume and stroke volume. Time-varying patterns of boundary voltage data originating from lung ventilation and cardiac blood flow were extracted from measured boundary voltage data using the principal component analysis (PCA) and independent component analysis (ICA). The source consistency theory was adopted to separately synthesize time-series of boundary voltage data associated with lung ventilation and cardiac blood flow. The respiratory volume signal (RVS) and cardiac volume signal (CVS) were extracted from reconstructed time-difference EIT images of lung ventilation and cardiac blood flow, respectively. After calibrating the volume signals using the mechanical ventilator and the invasive transpulmonary thermodilution (TPTD) method, tidal volume and stroke volume were computed as valley-to-peak values of the RVS and CVS, respectively. The difference in the tidal volume data between EIT and mechanical ventilator was within ± 20 ml from six pigs. The difference in the stroke volume data between EIT and TPTD was within ± 4.7 ml from the same animals. The results show the feasibility of the proposed method as a new noninvasive cardiopulmonary monitoring tool for simultaneous continuous measurements of stroke volume and tidal volume that are two most important vital signs. [ABSTRACT FROM AUTHOR]

Background: Recirculation during veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a known drawback that limits sufficient oxygenation. This study aimed to compare the short-term oxygenation and long-term mortality based on cannula configuration in patients with acute respiratory distress syndrome (ARDS) who receive VV-ECMO, especially in the absence of newly developed dual-lumen, single cannula. Methods: Data of patients with severe ARDS who received VV-ECMO from 2012 to 2015 at six hospitals were retrospectively analyzed. Primary outcomes were the partial pressure of oxygen (PaO2) at 1, 4, and 12 h after ECMO initiation and 180-day mortality. Results: Patients (n = 335) were divided into two groups based on the return cannula site: femoral vein (n = 178) or internal jugular vein (n = 157). The propensity score matching analysis generated 90 pairs, and baseline characteristics at admission, including PaO2, were similar between the groups. PaO2 at 1, 4 and 12 h after ECMO initiation were not different according to cannula configuration. Moreover, the increment in oxygenation from the baseline values was not different between the femoral and jugular group. PaCO2 level at 1, 4 and 12 h were significantly lower in the jugular group. The two groups did not differ in terms of mortality at 180 days after ECMO, however more cannula-related complications occurred in the jugular group. Conclusion: Regardless of the cannula configuration, patients with ARDS managed with VV-ECMO showed comparable clinical outcomes in terms of short-term oxygenation and long-term mortality. Nevertheless, further well-designed randomized control trials are warranted. [ABSTRACT FROM AUTHOR]

Background: We evaluated severe pain-related adverse events (SAE) during the percutaneous dilatational tracheostomy (PDT) procedure performed by a neurointensivist and compared the outcomes with that of conventional surgical tracheostomy in neurocritically ill patients.Methods: This was a retrospective and observational study of adult patients who were admitted to the neurosurgical intensive care unit between January 2014 and March 2018 and underwent tracheostomy. In this study, primary endpoints were incidence of SAE: cardiac arrest, arrhythmias, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. The secondary endpoint was procedure-induced complications.Results: A total of 156 patients underwent tracheostomy during the study. Elective surgery of brain tumors (34.0%) and intracranial hemorrhage (20.5%) were the most common reasons for admission. The most common reasons for tracheostomy were difficult ventilator weaning or prolonged intubation (42.9%) and sedative reduction (23.7%). Tachycardia (30.1%) and hypertension (30.1%) were the most common SAE. Incidence of SAE was more common in conventional tracheostomy compared to PDT (67.1% vs. 42.3%, P = 0.002). The total duration of SAE (19.8 ± 23.0 min vs. 3.4 ± 5.3 min, P < 0.001) and procedural time (42.2 ± 21.8 min vs. 17.7 ± 9.2 min, P < 0.001) were longer in conventional tracheostomy compared to PDT. Multivariable adjustment revealed that only PDT by a neurointensivist significantly reduced the incidence of SAE by one third (adjusted odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.187-0.691). In addition, PDT by a neurointensivist deceased the duration of SAE by 8.64 min (β: -8.64, 95% CI: - 15.070 - -2.205, P = 0.009) and prolonging the procedure time by every one minute significantly increased the duration of SAE by 6.38 min (β: 6.38, 95% CI: 0.166-0.470, P < 0.001). Procedure-induced complications were more common in conventional tracheostomy compared to PDT (23.5% vs. 11.3%, P = 0.047).Conclusions: This retrospective and exploratory study of our single-center limited cohort of tracheostomy patients revealed that decreased SAE may be associated with short procedural time during the PDT procedure performed by a neurointensivist. It is proposed that PDT by a neurointensivist may be safe and feasible in neurocritically ill patients. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Patients on extracorporeal life support (ECLS), like other critically ill patients, are transported to other institutions for various reasons. However, little has been reported concerning the characteristics and clinical outcomes of transported patients compared with those of in-house patients. METHODS A total of 281 adult patients received ECLS between January 2014 and August 2016. Patients who underwent cannulation at another institution by our team were excluded. Patients were divided into 2 groups: transported group (N =  46) and in-house group (N =  235). All 46 patients were safely transported without serious adverse events. The mean travel distance was 206±140 km, with a mean travel time of 78 ± 57 min. Following propensity score matching, 44 transported patients were matched to 148 in-house patients. RESULTS In the matched population, the mean age was 48 ± 13 years in the transported group and 49 ± 17 years in the in-house group (P  = 0.70). The ECLS type (venoarterial/venovenous) comprised 35/9 (79.5/20.5%) in the transported group and 119/29 (80.4/19.6%) in the in-house group (P =  0.93). Seventeen (38.6%) extracorporeal cardiopulmonary resuscitations were performed in the transported group and 59 (39.9%) were performed in the in-house group (P =  0.91). The incidence of limb ischaemia and acute kidney injury was higher in the transported group (P =  0.007 and P =  0.001, respectively). However, the rate of survival to discharge did not differ between the groups (63.6% in the transported group vs 64.2% in the in-house group, P =  0.94) and there was no difference in overall mortality (P  =   0.99). CONCLUSIONS Although transported patients had more complications than in-house ECLS patients, clinical outcomes were comparable in the matched population. Transporting ECLS patients to an experienced centre may be justified based on our experience. [ABSTRACT FROM AUTHOR]

There was a pandemic of influenza A (H1N1) in 2009; in Korea, there was also an H1N1 epidemic in 2016. We aim to investigate whether survival had improved in the setting of recent advances in intensive care unit (ICU) management. We conducted a retrospective analysis of acute respiratory failure patients with H1N1 influenza pneumonia in 2016 and 2009 respectively at two tertiary referral hospitals in Korea. A total of 28 patients were treated in 2016, and 34 in 2009. There was no significant difference in SOFA scores on ICU admission day. In-hospital mortality was significantly lower in patients of 2016 compared to those of 2009 (18% vs. 44% P = 0.028). By multivariable analyses, the treatment year 2016 was associated with a greater likelihood of survival. Compared to the patients treated in 2009, those treated in 2016 were one seventh as likely to die after adjusting for other clinical variables (hazard ratio for mortality, 0.15; 95% confidence interval. 0.03–0.63, P = 0.010). Improved survival in patients who underwent extracorporeal membrane oxygenation treatment (in-hospital mortality, 17% vs. 60%, P = 0.242) and decreased tidal volumes during mechanical ventilation (median 5.4 mL/kg vs. median 9.2 mL/kg, P = 0.018) were observed in 2016 compared to 2009. Treatment outcomes for patients with H1N1 acute respiratory failure improved from 2009 to 2016 in two tertiary referral centers in South Korea. [ABSTRACT FROM AUTHOR]

Purpose: Target temperature management (TTM) and extracorporeal cardiopulmonary resuscitation (ECPR) have been established as important interventions during cardiopulmonary arrest. However, the impact of combined TTM and ECPR on clinical outcomes has not been studied in detail. Methods: We reviewed the records of 245 patients who received extracorporeal life support (ECLS) between January 2012 and June 2015. Exclusion criteria were as follows: Extracorporeal life support performed for reasons other than cardiac arrest, age less than 18 years, and death within 24 hours. A total of 101 patients were finally included in the study. Twenty-five patients underwent TTM, and 76 patients did not. Results: The patients' mean age was 55 ± 16.7 years. The mean cardiac arrest time was 44.6 ± 33.5 minutes. There were 84 patients whose cardiac arrest was due to a cardiac cause (83.2%) and 79 patients with in-hospital cardiac arrest (78.2%). There was a significant difference in average body temperature during the first 24 hours following ECPR (33.4°C vs 35.6°C; P =.001). The overall favorable neurological outcome rate was 34% and hospital survival rate was 47%. There was no difference in favorable neurological outcomes and hospital survival between the TTM and non-TTM groups (P =.91 and.84, respectively). On multivariate analysis of neurological outcomes and hospital survival, TTM was not a significant prognostic factor. Conclusion: We did not observe any benefits of TTM in patients undergoing ECPR. Natural hypothermia or normothermia related to ECLS may explain this result. Further research is needed to understand the role of TTM in ECPR. [ABSTRACT FROM AUTHOR]

We evaluated the safety and feasibility of ultrasound-guided peripherally-inserted central venous catheters (PICC) by a neurointensivist at the bedside compared to fluoroscopy-guided PICC and conventional central venous catheter (CCVC). This was a retrospective study of adult patients who underwent central line placement and were admitted to the neurosurgical intensive care unit (ICU) between January 2014 and March 2018. In this study, the primary endpoint was central line-induced complications. The secondary endpoint was initial success of central line placement. Placements of ultrasound-guided PICC and CCVC performed at the bedside if intra-hospital transport was inappropriate. Other patients underwent PICC placement at the interventional radiology suite under fluoroscopic guidance. A total of 191 patients underwent central line placement in the neurosurgery ICU during the study period. Requirement for central line infusion (56.0%) and difficult venous access (28.8%) were the most common reasons for central line placement. The basilic vein (39.3%) and the subclavian vein (35.1%) were the most common target veins among patients who underwent central line placement. The placements of ultrasound-guided PICC and CCVC at the bedside were more frequently performed in patients on mechanical ventilation (p = 0.001) and with hemodynamic instability (p <0.001) compared to the fluoroscopy-guided PICC placement. The initial success rate of central line placement was better in the fluoroscopy-guided PICC placement than in the placements of ultrasound-guided PICC and CCVC at the bedside (p = 0.004). However, all re-inserted central lines were successful. There was no significant difference in procedure time between the three groups. However, incidence of insertional injuries was higher in CCVC group compared to PICC groups (p = 0.038). Ultrasound-guided PICC placement by a neurointensivist may be safe and feasible compared to fluoroscopy-guided PICC placement by interventional radiologists and CCVC placement for neurocritically ill patients. [ABSTRACT FROM AUTHOR]

Recent studies showed that physical and/or neuropsychiatric impairments significantly affect long-term mortality of ICU survivors. We conducted this study to investigate that simplified measurement of physical function and level of consciousness at hospital discharge by attending nurses could predict long-term outcomes after hospital discharge. A retrospective analysis of prospectively and retrospectively collected data of 246 patients who received medical ICU treatment was conducted. We grouped patients according to physical function and level of consciousness measured by the simplified method at hospital discharge as follow; group A included patients with alert mental and capable of walking or moving by wheel chairs; group B included those with alert mental and bed-ridden status; and Group C included those with confused mental and bed-ridden status. The two-year survival rate after hospital discharge was compared. Of 246 patients, 157 patients were included in the analysis and there were 103 survivors after two-year follow up. Compared to non-survivors, survivors were more likely to be younger (P = 0.026) and have higher body mass index (P = 0.019) and no malignant disease (P = 0.001). There were no statistically significant differences in treatment modalities including medication, use of medical devices, and physical therapy between the survivors and non-survivors. The analysis showed significant differences in survival between the groups classified by physical function (P < 0.001) and level of consciousness (P < 0.01). Multivariate analysis showed that survival rate was significantly lower among the patients in group C than in those in group B or group A (P < 0.001). Simplified method to assess physical function and level of consciousness at hospital discharge can predict long-term outcomes of medical ICU survivors. [ABSTRACT FROM AUTHOR]

There is conflicting evidence for the clinical benefit of statin therapy in patients with vasospastic angina (VSA). We investigated the association of statin therapy with clinical outcomes in relatively large populations with clinically suspected VSA from a nationwide population-based database. Data were collected from the Health Insurance Review and Assessment database records of 4,099 patients that were in an intensive care unit with VSA between January 1, 2008 and May 31, 2015. We divided the patients into a statin group (n = 1,795) and a non-statin group (n = 2,304). The primary outcome was a composite of cardiac arrest and acute myocardial infarction (AMI). The median follow-up duration was 3.8 years (interquartile range: 2.2 to 5.8 years). Cardiac arrest or AMI occurred in 120 patients (5.2%) in the statin group, and 97 patients (5.4%) in the non-statin group (P = 0.976). With inverse probability of treatment weighting, there was no significant difference in the rate of cardiac arrest or AMI between the two groups (adjusted hazard ratio [HR], 0.99; 95% confidence interval [CI], 0.76–1.30; P = 0.937), or even between the non-statin group and high-intensity statin group (adjusted HR, 1.08; 95% CI, 0.69–1.70; P = 0.75). The beneficial association of statin use with the primary outcome was consistently lacking across the various comorbidity types. Statin therapy was not associated with reduced cardiac arrest or AMI in patients with VSA, regardless of statin intensity. Prospective, randomized trials will be needed to confirm our findings. [ABSTRACT FROM AUTHOR]

Background: Intensive care unit (ICU) readmission is generally associated with increased hospital stays and increased mortality. However, there are limited data on ICU readmission in critically ill cancer patients. Method: We conducted a retrospective cohort study based on the prospective registry of all critically ill cancer patients admitted to the oncology medical ICU between January 2012 and December 2013. After excluding patients who were discharged to another hospital or decided to end-of-life care, we divided the enrolled patients into four groups according to the time period from ICU discharge to unexpected events (ICU readmission or ward death) as follows: no (without ICU readmission or death, n = 456), early (within 2 days, n = 42), intermediate (between 2 and 7 days, n = 64), and late event groups (after 7 days of index ICU discharge, n = 129). The independent risk factors associated with ICU readmission or unexpected death after ICU discharge were also analyzed using multinomial logistic regression model. Results: There were no differences in the reasons for ICU readmission across the groups. ICU mortality did not differ among the groups, but hospital mortality was significantly higher in the late event group than in the early event group. Mechanical ventilation during ICU stay, tachycardia, decreased mental status, and thrombocytopenia on the day of index ICU discharge increased the risk of early ICU readmission or unexpected ward death, while admission through the emergency room and sepsis and respiratory failure as the reasons for index ICU admission were associated with increased risk of late readmission or unexpected ward death. Interestingly, recent chemotherapy within 4 weeks before index ICU admission was inversely associated with the risk of late readmission or unexpected ward death. Conclusion: In critically ill cancer patients, patient characteristics predicting ICU readmission or unexpected ward death were different according to the time period between index ICU discharge and the events. [ABSTRACT FROM AUTHOR]

Background: Bacterial pneumonia is a major cause of acute respiratory distress syndrome (ARDS) requiring extracorporeal membrane oxygenation (ECMO) support. However, it is unknown whether the type of pneumonia, community-acquired pneumonia (CAP) versus hospital-acquired pneumonia (HAP), should be considered when predicting outcomes for ARDS patients treated with ECMO. Methods: We divided a sample of adult patients receiving ECMO for acute respiratory distress syndrome caused by bacterial pneumonia between January 2012 and December 2016 into CAP (n = 21) and HAP (n = 35) groups and compared clinical and bacteriological characteristics and outcomes. Results: The median acute physiology and chronic health evaluation II and sequential organ failure assessment scores were 22 and 8, respectively, in the CAP and HAP groups. The most commonly identified organism in the CAP group was Streptococcus pneumonia (n = 12, 57.1%), while Acinectobacter baumanii was the most commonly identified in the HAP group (n = 13, 37.1%). However, the incidence of multidrug resistant bacteria was not different between groups (57.1% versus 74.3%, p = 0.125). Of the 56 patients in the study, 26 were successfully weaned from ECMO, and 20 were discharged from the hospital. There were no significant differences in ECMO weaning rate (47.6% versus 45.7%, p > 0.999) or survival to discharge rate (33.3% versus 37.1%, p > 0.999) between the two groups. The 30-day and 90-day mortality rates were also similar. Conclusion: Patients with CAP and HAP who received ECMO for respiratory support had similar characteristics and clinical outcomes. [ABSTRACT FROM AUTHOR]

ABSTRACT: Background and objective: Limb muscle weakness is associated with difficult weaning. However, there are limited data on extubation failure. The objective of this cohort study was to evaluate the association between limb muscle weakness according to the Medical Research Council (MRC) scale and extubation failure rates among patients in a medical intensive care unit (ICU). Methods: All consecutive medical ICU patients who were mechanically ventilated for more than 24 h and who were weaned according to protocol were prospectively registered, and limb muscle weakness was assessed using the MRC scale on the day of planned extubation. Association of limb muscle weakness with extubation failure within 48 h following planned extubation was evaluated with logistic regression analysis. Results: Over the study period, 377 consecutive patients underwent planned extubation through a standardized weaning process. Extubation failure occurred in 106 (28.1%) patients. Median scores on the MRC scale for four limbs were lower in patients with extubation failure (14, interquartile range (IQR) 12–16) than in patients without extubation failure (16, IQR 12–18; P = 0.024). In addition, extubation failure rates decreased significantly with increasing quartiles of MRC scores (P for trend <0.001). In multivariable analysis, MRC scores ≤10 points were independently associated with extubation failure within 48 h (adjusted OR 2.131, 95% CI: 1.071–4.240, P = 0.031). Conclusion: Limb muscle weakness assessed on the day of extubation was found to be independently associated with higher extubation failure rates within 48 h following planned extubation in medical patients. [ABSTRACT FROM AUTHOR]

Background: Acute respiratory distress syndrome (ARDS) is potentially underrecognized by clinicians. Early recognition and subsequent optimal treatment of patients with ARDS may be facilitated by usage of biomarkers. Surfactant protein D (SP-D), a marker of alveolar epithelial injury, has been proposed as a potentially useful biomarker for diagnosis of ARDS in a few studies. We tried to validate the performance of plasma SP-D levels for diagnosis of ARDS.Methods: We conducted a retrospective analysis using data from three (two in USA and one in Korea) prospective biobank cohorts involving 407 critically ill patients admitted to medical intensive care unit (ICU). A propensity score matched analysis (patients with versus without ARDS, matched 1:1) was carried out using significant variables from multiple logistic regression. The diagnostic accuracy of plasma SP-D as a diagnostic marker of ARDS was assessed by receiver operating characteristic curve analysis.Results: Out of the 407 subjects included in this study, 39 (10%) patients fulfilled ARDS criteria. Patients with ARDS had higher SP-D levels in plasma (p < 0.01) and higher hospital-mortality (p < 0.001) than those without ARDS. Thirty eight subjects with ARDS (cases) were successfully matched for propensity for ARDS with 38 subjects without ARDS (controls). Plasma levels of SP-D were higher in cases with ARDS compared to their matched controls without ARDS [median 20.8 ng/mL (interquartile range, 12.7-38.4) versus 7.9 (4.1-17.0); p = 0.001]. The area under the receiver operating characteristic curve for SP-D for the diagnosis of ARDS was 0.71 (95% confidence intervals, 0.60-0.83). A cut-off point of 12.7 ng/mL for SP-D yielded sensitivity of 74% and specificity of 63%.Conclusions: High levels of SP-D within 48 h after ICU admission might serve as a diagnostic marker for ARDS in patients hospitalized in medical ICU. Further prospective trials are required to validate the diagnostic role of SP-D in ARDS, and if its usefulness is greater in direct than in indirect ARDS, as well as across different strata of severity of ARDS. [ABSTRACT FROM AUTHOR]

Background: Obesity might be associated with disturbance of cannulation in situation of extracorporeal cardiopulmonary resuscitation (ECPR). However, limited data are available on obesity in the setting of ECPR. Therefore, we investigated the association between body mass index (BMI) and clinical outcome in patients underwent ECPR. Methods: From January 2004 to December 2013, in-hospital cardiac arrest patients who had ECPR were enrolled from a single-center registry. We divided patients into four group according to BMI defined with the WHO classification (underweight, BMI < 18.5, n = 14; normal weight, BMI = 18.5–24.9, n = 118; overweight, BMI = 25.0–29.9, n = 53; obese, BMI ≥ 30, n = 15). The primary outcome was survival to hospital discharge. Results: Analysis was carried out for a total of 200 adult patients (39.5% females). Their median BMI was 23.20 (interquartile range, 20.93–25.80). The rate of survival to hospital discharge was 31.0%. There was no significant difference in survival to hospital discharge among the four groups (underweight, 35.7%; normal, 31.4%; overweight, 30.2%; obese, 26.7%, p = 0.958). Neurologic outcomes (p = 0.85) and procedural complications (p = 0.40) were not significantly different among the four groups either. SOFA score, initial arrest rhythm, and CPR to extracorporeal membrane oxygenation (ECMO) pump on time were significant predictors for survival to discharge, but not BMI. Conclusion: BMI was not associated with in-hospital mortality who underwent ECPR. Neurologic outcomes at discharge or procedural complications following ECPR were not related with BMI either. [ABSTRACT FROM AUTHOR]

Background: Limited data are available on imaging predictors of neurological outcomes after extracorporeal cardiopulmonary resuscitation (ECPR). We investigated the association of initial brain computed tomography (CT) findings with neurological outcomes following ECPR.Methods: Between February 2005 and December 2015, a total of 42 patients who underwent brain CT scans within 48 h after ECPR were analyzed. Loss of the boundary between gray matter and white matter (LOB) or cortical sulcal effacement (SE), gray-to-white matter ratio (GWR), and optic nerve sheath diameter (ONSD) were measured on initial brain CT. The primary outcome was the Cerebral Performance Categories (CPC) scale at discharge.Results: Of the 42 adult ECPR patients, 23 (54.8%) patients survived to discharge and 19 (45.2%) patients had good neurological outcomes (CPC 1 and 2). The area under the curve (AUC) of GWR in the basal ganglia (GWR-BG) was 0.792 (95% confidence interval (CI), 0.639-0.901, p = 0.001). ONSD (AUC 0.745; 95% CI, 0.587 - 0.867, p = 0.007) was 5.57 (interquartile range (IQR) 5.14 - 5.98) mm in the good neurological outcome group versus 6.07 (IQR 5.71 - 6.64) mm in the poor outcome group. LOB or SE were more often detected in the poor neurological outcome group (AUC 0.817; 95% CI, 0.682-0.952, p <0.001). The predictive performance of poor neurological outcomes of a composite of GWR-BG, ONSD, and LOB/SE was significantly improved (AUC 0.904; 95% CI, 0.773-0.973) compared to when each brain CT marker was considered separately (GWR-BG, p = 0.048; ONSD, p = 0.026; LOB/SE, p = 0.028).Conclusions: GWR, ONSD, and LOB/SE on initial brain CT scans are associated with neurological prognosis in patients who underwent ECPR. The new risk prediction model, which uses a composite of GWR, ONCD, and LOB/SE, could provide better information on neurologic outcomes in patients underwent ECPR. [ABSTRACT FROM AUTHOR]

We evaluated the association of body temperature patterns with neurological outcomes after extracorporeal cardiopulmonary resuscitation (ECPR). Between December 2013 and December 2015, we enrolled 48 patients with cardiac arrest who survived for at least 24 hours after ECPR. Based on their body temperature patterns and the intention to control fever, we divided the patients into those in whom fever was actively controlled (N = 25), those with normothermia (N = 17), and those with unintended hypothermia (N = 6). The primary outcome was the Cerebral Performance Categories (CPC) scale at discharge. Of the 48 ECPR patients, 23 patients (47.9%) had good neurological outcomes (CPC 1 and 2) and 27 patients (56.3%) survived to discharge. The normothermia group showed a pattern of higher temperatures compared with the other groups during 48 hours after ECPR. Not only poor neurological outcomes but also intensive care unit (ICU) mortality occurred more often in the unintended hypothermia group than in the other two groups, regardless of the fever control strategy (p = 0.023 and p = 0.002, respectively). There were no differences in neurological outcomes and ICU mortality between the actively controlled fever group and the normothermia group (p = 0.845 and p = 0.616, respectively). Unintentionally sustained hypothermia may be associated with poor neurological outcomes after ECPR. These findings suggest that patients who are unable to generate a fever following ECPR may incur severe hypoxic brain injury. [ABSTRACT FROM AUTHOR]

Purpose: Limited data are available on the intracranial haemorrhage (ICH) developed in critically ill cancer patients during their stay in the intensive care unit (ICU).Methods: All consecutive patients who underwent brain CT for suspicion of spontaneous intracerebral haemorrhage (ICH) with acute neurologic symptoms or signs developed during their ICU stay were retrospectively evaluated to identify predictors of ICH.Results: Over the study period, a total of 273 patients underwent brain CT scanning for suspicion of ICH, with altered mentality in 202 (74 %), seizure in 43 (16 %), and hemiparesis in 34 (13 %). However, only 49 (18 %) patients had a final diagnosis of ICH. The most common type of haemorrhage was intracerebral in 34 patients (69 %), followed by subarachnoidal haemorrhage in 17 (35 %). In multiple logistic regression analysis, anisocoric pupils or abnormal pupil reflex (adjusted OR 7.939; 95 % CI, 2.315-27.228) was an independent predictor of ICH. In addition, higher positive end-expiratory pressure (adjusted OR 1.204; 95 % CI, 1.065-1.361) was significantly associated with ICH. However, platelet count was inversely associated with ICH (adjusted OR 0.993; 95 % CI 0.988-0.999).Conclusion: Brain CT scanning should be performed even in critically ill cancer patients, especially with risk factors and acute neurologic changes. [ABSTRACT FROM AUTHOR]