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Purpose: Studies of critically ill hematopoietic stem cell transplantation (HSCT) recipients have mainly been single-center and focused on allogenic HSCT recipients. We aimed to describe a cohort of autologous HSCT with an unplanned intensive care unit (ICU) admission., Methods: This study is a retrospective cohort study of autologous HSCT performed as a treatment for a hematological malignancy, during their first unplanned ICU admission in 50 hospitals in Brazil. We assessed the hospital mortality and the association between mechanical ventilation, vasopressors, and renal replacement therapy and hospital mortality in autologous HSCT recipients, adjusted for potential confounders., Results: We included 301 patients. Multiple myeloma was the most common malignancy driving to HSCT. ICU and hospital mortality were 22.9% and 37.5%, respectively. After adjustment for potential confounders, mechanical ventilation (OR = 9.10; CI 95%, 4.82-17.15) was associated with hospital mortality, but vasopressors (OR = 1.43; CI 95%, 0.77-2.64) and renal replacement therapy (OR = 1.30; CI 95%, 0.63-2.66) were not., Conclusions: In this large cohort of critically ill autologous HSCT recipients, mechanical ventilation was the only organ support-therapy associated with increased mortality in autologous HSCT recipients., Competing Interests: Declaration of Competing Interest MS is founder of Epimed Monitor®, an electronic healthcare system used to collect data and track ICU quality metrics. FGZ has received grants for investigator-initiated studies from Ionis Pharmaceuticals (USA), Bactiguard (Sweden) and Brazilian Ministry of Health, none related to the scope of this study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To describe fluid resuscitation practices in Brazilian intensive care units and to compare them with those of other countries participating in the Fluid-TRIPS., Methods: This was a prospective, international, cross-sectional, observational study in a convenience sample of intensive care units in 27 countries (including Brazil) using the Fluid-TRIPS database compiled in 2014. We described the patterns of fluid resuscitation use in Brazil compared with those in other countries and identified the factors associated with fluid choice., Results: On the study day, 3,214 patients in Brazil and 3,493 patients in other countries were included, of whom 16.1% and 26.8% (p < 0.001) received fluids, respectively. The main indication for fluid resuscitation was impaired perfusion and/or low cardiac output (Brazil: 71.7% versus other countries: 56.4%, p < 0.001). In Brazil, the percentage of patients receiving crystalloid solutions was higher (97.7% versus 76.8%, p < 0.001), and 0.9% sodium chloride was the most commonly used crystalloid (62.5% versus 27.1%, p < 0.001). The multivariable analysis suggested that the albumin levels were associated with the use of both crystalloids and colloids, whereas the type of fluid prescriber was associated with crystalloid use only., Conclusion: Our results suggest that crystalloids are more frequently used than colloids for fluid resuscitation in Brazil, and this discrepancy in frequencies is higher than that in other countries. Sodium chloride (0.9%) was the crystalloid most commonly prescribed. Serum albumin levels and the type of fluid prescriber were the factors associated with the choice of crystalloids or colloids for fluid resuscitation.

Purpose: To customize and externally validate the recently proposed Simplified Mortality Score for the ICU (SMS-ICU, a simple score for 90-day mortality that has no need for ancillary testing results) for in-hospital mortality and to compare its performance to SAPS 3., Material and Methods: We used data from two distinct large cohorts of adult Brazilian patients with unplanned ICU admissions to perform a first-level customization (43,017 patients admitted to 78 ICUs) of the original SMS-ICU score for in-hospital mortality and, sequentially, externally validate it (313,365 patients admitted to 99 ICUs). Performance of SMS-ICU was assessed through measurements of discrimination and calibration and compared with SAPS 3., Results: In the validation cohort, median SMS-ICU was 13 (IQR 8-16) points and median SAPS 3 was 44 (IQR 36-51). Discrimination of SMS-ICU was good (AUC 0.817; 95% CI 0.814-0.819) but slightly lower than of SAPS 3 (AUC 0.845; 95% CI 0.843-0.848;). The customized SMS-ICU predictions were comparable to SAPS 3 in terms of calibration., Conclusion: In this external validation of the SMS-ICU in a large Brazilian cohort, we observed good discrimination of SMS-ICU and acceptable calibration after first-level customization. SMS-ICU can be used as a measure of illness severity for acutely admitted ICU patients in clinical studies., Competing Interests: Declaration of Competing Interest MS and JIFS are proprietary and founder of Epimed Solutions®, a cloud-based registry for intensive care units that was used for the ORCHESTRA database. AG, AP, and MHM were involved in the development of the SMS-ICU. The ICU, Rigshospitalet receives fund for other research projects from Ferring Pharmaceuticals, Denmark, and the Novo Nordisk Foundation, Denmark., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Frail patients are known to experience poor outcomes. Nevertheless, we know less about how frailty manifests itself in patients' physiology during critical illness and how it affects resource use in intensive care units (ICU). We aimed to assess the association of frailty with short-term outcomes and organ support used by critically ill patients., Methods: Retrospective analysis of prospective collected data from 93 ICUs in Brazil from 2014 to 2015. We assessed frailty using the modified frailty index (MFI). The primary outcome was in-hospital mortality. Secondary outcomes were discharge home without need for nursing care, ICU and hospital length of stay (LOS), and utilization of ICU organ support and transfusion. We used mixed logistic regression and competing risk models accounting for relevant confounders in outcome analyses., Results: The analysis consisted of 129,680 eligible patients. There were 40,779 (31.4%) non-frail (MFI = 0), 64,407 (49.7%) pre-frail (MFI = 1-2) and 24,494 (18.9%) frail (MFI ≥ 3) patients. After adjusted analysis, frailty was associated with higher in-hospital mortality (OR 2.42, 95% CI 1.89-3.08), particularly in patients admitted with lower SOFA scores. Frail patients were less likely to be discharged home (OR 0.36, 95% CI 0.54-0.79) and had higher hospital and ICU LOS than non-frail patients. Use of all forms of organ support (mechanical ventilation, non-invasive ventilation, vasopressors, dialysis and transfusions) were more common in frail patients and increased as MFI increased., Conclusions: Frailty, as assessed by MFI, was associated with several patient-centered endpoints including not only survival, but also ICU LOS and organ support.

Objective: To examine the associations between the scientific output of Brazilian intensive care units and their organizational characteristics. Methods: This study is a re-analysis of a previous retrospective cohort that evaluated organizational intensive care unit characteristics and their associations with outcomes. We analyzed data from 93 intensive care units across Brazil. Intensive care units were assessed for scientific productivity and the effects of their research activities, using indicators of care for comparison. We defined the most scientifically productive intensive care units as those with numerous publications and a SCImago Journal Rank score or an H-index above the median values of the participating intensive care units. Results: Intensive care units with more publications, higher SCImago Journal Rank scores and higher H-index scores had a greater number of certified intensivists (median of 7; IQR 5 - 10 versus 4; IQR 2 - 8; with p < 0.01 for the comparison between intensive care units with more versus fewer publications). Intensive care units with higher SCImago Journal Rank scores and H-index scores also had a greater number of fully implemented protocols (median of 8; IQR 6 - 8 versus 5; IQR 3.75 - 7.25; p < 0.01 for the comparison between intensive care units with higher versus lower SCImago Journal Rank scores). Conclusions: Scientific engagement was associated with better staffing patterns and greater protocol implementation, suggesting that research activity may be an indicator of better intensive care unit organization and care delivery. [ABSTRACT FROM AUTHOR]

Purpose: This is the first of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on resuscitation fluids in adult critically ill patients. This part addresses fluid choice and the other two will separately address fluid amount and fluid removal., Methods: This guideline was formulated by an international panel of clinical experts and methodologists. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision., Results: For volume expansion, the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general (moderate certainty of evidence), in patients with sepsis (moderate certainty of evidence), in patients with acute respiratory failure (very low certainty of evidence) and in patients in the perioperative period and patients at risk for bleeding (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than albumin in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using albumin rather than crystalloids in patients with cirrhosis (very low certainty of evidence). The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general (low certainty of evidence), in patients with sepsis (low certainty of evidence) and in patients with kidney injury (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using isotonic crystalloids rather than small-volume hypertonic crystalloids in critically ill patients in general (very low certainty of evidence)., Conclusions: This guideline provides eleven recommendations to inform clinicians on resuscitation fluid choice in critically ill patients., (© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.)

The article from Critical Care Science discusses the importance of comprehensive geriatric assessment in tailoring treatment for frail postintensive care patients. Frailty is described as a treatable clinical syndrome with a measurable biological basis, separate from but related to older age, multimorbidity, or disability. The article highlights the bidirectional relationship between critical illness and frailty status, emphasizing the need for personalized care models based on the Comprehensive Geriatric Assessment process to optimize patient outcomes in post-ICU care. [Extracted from the article]

To externally validate the Hospital Frailty Risk Score (HFRS) in critically ill patients. We selected older adult (≥ 75 years old) hospitalizations receiving mechanical ventilation, using the Nationwide Readmissions Database (January 1, 2016-November 30, 2018). Frailty risk was subcategorized into low-risk (HFRS score < 5), intermediate-risk (score 5–15), and high-risk (score > 15). We evaluated the HFRS to predict in-hospital mortality, prolonged hospitalization, and 30-day readmissions, using multivariable logistic regression, adjusting for patient and hospital characteristics. Model performance was assessed using the c-statistic, Brier score, and calibration plots. Among 649,330 weighted hospitalizations, 9.5%, 68.3%, and 22.2% were subcategorized as low-, intermediate-, and high-risk for frailty, respectively. After adjustment, high-risk patient hospitalizations were associated with increased risks of prolonged hospitalization (adjusted odds ratio [aOR] 5.59 [95% confidence interval [CI] 5.24–5.97], c-statistic 0.694, Brier 0.216) and 30-day readmissions (aOR 1.20 [95% CI 1.13–1.27], c-statistic 0.595, Brier 0.162), compared to low-risk hospitalizations. Conversely, high-risk hospitalizations were inversely associated with in-hospital mortality (aOR 0.46 [95% CI 0.45–0.48], c-statistic 0.712, Brier 0.214). The HFRS was not successfully validated to predict in-hospital mortality in critically ill older adults. While it may predict other outcomes, its use should be avoided in the critically ill. [ABSTRACT FROM AUTHOR]

Introduction: Frailty is common in critically ill patients and is associated with increased morbidity and mortality. There remains uncertainty as to the optimal method/timing of frailty assessment and the impact of care processes and adverse events on outcomes is unknown. We conducted a pilot study to inform on the conduct, design and feasibility of a multicenter study measuring frailty longitudinally during critical illness, care processes, occurrence of adverse events, and resultant outcomes. Methods: Single-center pilot study enrolling patients over the age of 55 admitted to an Intensive Care Unit (ICU) for life-support interventions including mechanical ventilation, vasopressor therapy and/or renal replacement therapy. Frailty was measured on ICU admission and hospital discharge with the Clinical Frailty Scale (CFS), the Frailty Index (FI) and CFS at 6-month follow-up. Frailty was defined as CFS ≥ 5 and a FI ≥ 0.20. Processes of care and adverse events were measured during their ICU and hospital stay including nutritional support, mobility, nosocomial infections and delirium. ICU, hospital and 6 months were determined. Results: In 49 patients enrolled, the mean (SD) age was 68.7 ± 7.9 with a 6-month mortality of 29%. Enrollment was 1 patient/per week. Frailty was successfully measured at different time points during the patients stay/follow-up and varied by method/timing of assessment; by CFS and FI, respectively, in 17/49 (36%), 23/49 (47%) on admission, 22/33 (67%), 21/33 (63%) on hospital discharge and 11/30 (37%) had a CFS ≥ 5 at 6 months. Processes of care and adverse events were readily captured during the ICU and ward stay with the exception of ward nutritional data. ICU, hospital outcomes and follow-up outcomes were worse in those who were frail irrespective of ascertainment method. Pre-existing frailty remained static in survivors, but progressed in non-frail survivors. Discussion: In this pilot study, we demonstrate that frailty measurement in critically ill patients over the course and recovery of their illness is feasible, that processes of care and adverse events are readily captured, have developed the tools and obtained data necessary for the planning and conduct of a large multicenter trial studying the interaction between frailty and critical illness. [ABSTRACT FROM AUTHOR]

Background: There are currently no validated globally and freely available tools to estimate the modified frailty index (mFI). The widely available and non-proprietary International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) coding could be used as a surrogate for the mFI. We aimed to establish an appropriate set of the ICD-10 codes for comorbidities to be used to estimate the eleven-variable mFI.Methods: A three-stage, web-based, Delphi consensus-building process among a panel of intensivists and geriatricians using iterative rounds of an online survey, was conducted between March and July 2021. The consensus was set a priori at 75% overall agreement. Additionally, we assessed if survey responses differed between intensivists and geriatricians. Finally, we ascertained the level of agreement.Results: A total of 21 clinicians participated in all 3 Delphi surveys. Most (86%, 18/21) had more than 5-years' experience as specialists. The agreement proportionately increased with every Delphi survey. After the third survey, the panel had reached 75% consensus in 87.5% (112/128) of ICD-10 codes. The initially included 128 ICD-10 variables were narrowed down to 54 at the end of the 3 surveys. The inter-rater agreements between intensivists and geriatricians were moderate for surveys 1 and 3 (κ = 0.728, κ = 0.780) respectively, and strong for survey 2 (κ = 0.811).Conclusions: This quantitative Delphi survey of a panel of experienced intensivists and geriatricians achieved consensus for appropriate ICD-10 codes to estimate the mFI. Future studies should focus on validating the mFI estimated from these ICD-10 codes.Trial Registration: Not applicable. [ABSTRACT FROM AUTHOR]

Background: Major emergency abdominal surgery is associated with excess mortality. Transfusion is known to be associated with increased morbidity and emergency surgery is an independent risk factor for perioperative transfusion. The primary objectives of this study were to identify risk factors for transfusion, and secondarily to investigate the influence of transfusion on clinical outcomes after major emergency abdominal surgery. Study design and methods: This study combined retrospective observational data including intraoperative, postoperative, and transfusion data in patients undergoing major emergency abdominal surgery from January 2010 to October 2016 at a Danish university hospital. The primary outcome was a transfusion of any kind from initiation of surgery to postoperative day 7. Secondary outcomes included 7-, 30-, 90-day and long-term mortality (median follow-up = 34.6 months, IQR = 13.0–58.3), lengths of stay, and surgical complication rate (Clavien–Dindo score ≥ 3a). Results: A total of 1288 patients were included and 391 (30%) received a transfusion of any kind. Multivariate logistic regression identified age, hepatic comorbidity, cardiac comorbidity, post-surgical anemia, ADP-receptor inhibitors, acetylsalicylic acid, anticoagulants, and operation type as risk factors for postoperative transfusion. 60.1% of the transfused patients experienced a serious surgical complication within 30 days of surgery compared with 28.1% of the non-transfused patients (p < 0.001). Among patients receiving a postoperative transfusion, unadjusted long-term mortality was increased with a hazard ratio of 3.8 (95% CI 2.9–5.0), p < 0.01. Transfused patients had significantly higher mortality at 7-, 30-, 90- and long-term, as well as a longer hospital stay but in the multivariate analyses, transfusion was not associated with mortality. Conclusion: Peri- and postoperative transfusion in relation to major emergency abdominal surgery was associated with an increased risk of postoperative complications. The potential benefits and harms of blood transfusion and clinical significance of pre- and postoperative anemia after major emergency abdominal surgery should be further studied in clinical prospective studies. [ABSTRACT FROM AUTHOR]

Background: The complications from coronavirus disease 2019 (COVID-19) have been the subject of study in diverse scientific reports. However, many aspects that influence the prognosis of the disease are still unknown, such as frailty, which inherently reduces resistance to disease and makes people more vulnerable. This study aimed to explore the complications of COVID-19 in patients admitted to a third-level hospital and to evaluate the relationship between these complications and frailty. Methods: An observational, descriptive, prospective study was performed in 2020. A sample of 254 patients from a database of 3,112 patients admitted to a high-level hospital in Madrid, Spain was analyzed. To assess frailty (independent variable) the Clinical Frailty Scale (CFS) was used. The outcome variables were sociodemographic and clinical, which included complications, length of stay, intensive care unit (ICU) admission and prognosis. Results: A total of 13.39% of the patients were pre-frail and 17.32% were frail. Frail individuals had a shorter hospital stay, less ICU admission, higher mortality and delirium, with statistical significance. Conclusion: Frailty assessment is a crucial approach in patients with COVID-19, given a higher mortality rate has been demonstrated amongst frail patients. The CFS could be a predictor of mortality in COVID-19. [ABSTRACT FROM AUTHOR]

Hematological malignant tumors represent a group of major diseases carrying a substantial risk to the lives of affected patients. Risk factors for mortality in critically ill patients have garnered substantial attention in recent research endeavors. The present research aimed to identify factors predicting intensive care unit (ICU) mortality in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). Furthermore, the present study analyzed and compared the mortality rate between patients undergoing haploidentical hematopoietic stem cell transplantation (Haplo-SCT) and those undergoing identical sibling donor (ISD) transplantation. A total of 108 patients were included in the present research, 83 (76.9%) of whom underwent Haplo-SCT. ICU mortality was reported in 58 (53.7%) patients, with the values of 55.4 and 48.0% associated with Haplo-SCT and ISD, respectively (P=0.514). The mortality rate of patients undergoing Haplo-SCT was comparable to that of patients undergoing ISD transplantation. The present study found that reduced hemoglobin, elevated total bilirubin, elevated brain natriuretic peptide, elevated fibrinogen degradation products, need for vasoactive drugs at ICU admission, need for invasive mechanical ventilation and elevated APACHE II scores were independent risk factors for ICU mortality. Among patients presenting with 5-7 risk factors, the ICU mortality reached 100%, significantly exceeding that of other patients. The present research revealed that ICU mortality rates remain elevated among patients who underwent allo-HSCT, especially those presenting multiple risk factors. However, the outcome of patients undergoing Haplo-SCT were comparable to those of patients undergoing ISD transplants. [ABSTRACT FROM AUTHOR]

Purpose: Invasive mechanical ventilation is a common form of life support provided to critically ill patients. Frailty is an emerging prognostic factor for poor outcome in the Intensive Care Unit (ICU); however, its association with adverse outcomes following invasive mechanical ventilation is unknown. We sought to evaluate the association between frailty, defined by the Clinical Frailty Scale (CFS), and outcomes of ICU patients receiving invasive mechanical ventilation.Methods: We performed a retrospective analysis (2011-2016) of a prospectively collected registry from two hospitals of consecutive ICU patients ≥ 18 years of age receiving invasive mechanical ventilation. CFS scores were based on recorded pre-admission function at the time of hospital admission. The primary outcome was hospital mortality. Secondary outcomes included discharge to long-term care, extubation failure at time of first liberation attempt, and tracheostomy.Results: We included 8110 patients, and 2529 (31.2%) had frailty (CFS ≥ 5). Frailty was associated with increased odds of hospital death (adjusted odds ratio [aOR]: 1.24 [95% confidence interval [CI] 1.10-1.40) and discharge to long-term care (aOR 1.21 [95% CI 1.13-1.35]). As compared to patients without frailty, patients with frailty had increased odds of extubation failure (aOR 1.17 [95% CI 1.04-1.37]), hospital death following extubation failure (aOR 1.18 [95% CI 1.07-1.28]), tracheostomy (aOR 1.17 [95% CI 1.01-1.36]), and hospital death following tracheostomy (aOR 1.14 [95% CI 1.03-1.25]).Conclusions: The presence of frailty among patients receiving mechanical ventilation is associated with increased odds of hospital mortality, discharge to long-term care, extubation failure, and need for tracheostomy. [ABSTRACT FROM AUTHOR]

Very old intensive care patients (VIPs >= 80 years of age) are vulnerable. This, in line with the patient's values and preferences, considering the baseline prognosis of the patient and accounting for a realistic potential outcome, should guide the treatment plan in an attempt to achieve the best feasible final outcome. In a cohort of old patients with severe acute kidney injury in Canada, the decision for renal replacement therapy was largely influenced by patient-specific factors and by clinician perception of benefit [[13]]. 10.1001/jama.2015.11068 8 Harris S, Singer M, Sanderson C, Grieve R, Harrison D, Rowan K. Impact on mortality of prompt admission to critical care for deteriorating ward patients: an instrumental variable analysis using critical care bed strain. [Extracted from the article]

Background: The prevalence of frailty, an important risk factor for short- and long-term outcomes in hospitalized adults, differs by sex. Studies in critically ill adults have also found differences in mortality and organ support rates in males and females. The objective of this study was to determine if these observed differences in mortality and organ support rates can be explained by sex and frailty alone, or if the interaction between sex and frailty is an important risk factor. Methods: This is a retrospective multi-centre population-based cohort study of all adult patients (≥ 18 years) admitted to the seventeen intensive care units (ICUs) across Alberta, Canada, between 2016 and 2017. On admission, physicians assigned a Clinical Frailty Scale (CFS) score (1 = very fit, 9 = terminally ill) to all patients. Patients with missing CFS scores or who died within 24 h of ICU admission were excluded. Frailty was defined as CFS ≥ 5. Outcomes included all-cause hospital mortality, ICU mortality, and organ support rates. A propensity score for female sex was generated and 1:1 matching on sex was performed. Multivariable Cox regression or logistic regression, as appropriate, was performed to evaluate the association between sex, frailty, and the sex-frailty interaction term with outcomes. Results: Of 15,238 patients included in the cohort, after propensity score matching 11,816 patients remained (mean [standard deviation] age 57.3 [16.9]). In the matched cohort, females had a higher prevalence of frailty than males (32% vs. 27%, respectively) and higher odds of frailty (odds ratio [95% confidence interval (CI)] 1.29 [1.20–1.40]). Though females were less likely to receive invasive mechanical ventilation (hazard ratio [95% CI] 0.78 [0.71–0.86]), the interaction between sex and frailty (i.e., males and females with and without frailty) was not associated with differences in organ support rates. Receipt of dialysis and vasoactive support, as well as hospital mortality and ICU mortality were associated with frailty but were not associated with female sex or the interaction between sex and frailty. Conclusions: Although frailty and sex were individually associated with mortality and differences in organ support in the ICU, there does not appear to be a significant interaction between sex and frailty with regards to these outcomes. [ABSTRACT FROM AUTHOR]