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Background: Limited data are available on the association of malnutrition with the occurrence of delirium in the cardiac intensive care unit (CICU). Thus, we aimed to analyze whether nutritional indices and their components can predict the development of delirium in CICU., Methods: We enrolled 2,783 patients admitted to the CICU of Samsung Medical Center for more than 24 h between September 2012 and December 2018. We assessed the nutritional status at admission using three indices, the Prognostic Nutrition Index (PNI), the Geriatric Nutritional Risk Index (GNRI), and the Controlling Nutritional Status (CONUT). Then, we compared predictive performances for the occurrence of delirium among nutritional indices using Delong's test., Results: Delirium developed in 678 patients (24.3%) assessed three times daily for 7 days of CICU stay. Nutritional indices had fair predictive performance for development of delirium in critically ill cardiac patients using the area under the receiver-operating characteristic curve (AUROC: 0.729 for the GNRI, 0.728 for PNI, and 0.762 for CONUT). Furthermore, the AUROC of albumin alone (0.77, 95% CI, 0.75-0.79) was significantly greater than that of either GNRI ( p < 0.001) or PNI ( p < 0.001). In a multivariable analysis including each component of nutritional indices, albumin was a significant predictor for delirium but not absolute lymphocyte count, bodyweight/ideal bodyweight, or total cholesterol level as a component of nutritional indices., Conclusion: Predictive performances of nutritional indices for the occurrence of delirium were acceptable in patients admitted to CICU. Albumin alone might be a helpful and straightforward indicator for the occurrence of delirium., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Kim, Ko, Na, Chung, Choi, Park and Yang.)

Objective: Continuous renal replacement therapy (CRRT) is the standard treatment for critically ill patients with acute kidney injury (AKI). Electrolyte disturbance such as hypokalemia or hypophosphatemia occurs paradoxically in patients undergoing CRRT due to high clearance. We developed a fluid management protocol for dialysate and replacement fluid that depends on serum electrolytes and focuses on potassium and phosphate levels to prevent electrolyte disturbance during CRRT. The impact of our new fluid protocol on electrolyte stability was evaluated., Methods: Adult patients who received CRRT between 2013 and 2017 were included. Patients treated 2 years before (2013-2014; pre-protocol group) and 2 years following development of the fluid protocol (2016-2017; protocol group) were compared. The primary outcomes were individual coefficient of variation (CV) and abnormal event rates of serum phosphate and potassium. Secondary outcomes were frequency of electrolyte replacement and incidence of cardiac arrhythmias. Individual CV and abnormal event rates for each electrolyte were analyzed using the Wilcoxon rank-sum test and Chi-square test with Yates' continuity correction., Results: A total of 1,448 patients was included. Both serum phosphate and potassium were higher in the protocol group. The CVs of serum phosphate (pre-protocol vs. protocol, 0.275 [0.207-0.358] vs. 0.229 [0.169-0.304], p < 0.01) and potassium (0.104 [0.081-0.135] vs. 0.085 [0.064-0.110], p < 0.01) were significantly lower in the protocol group. The abnormal event rates of serum phosphate (rate [95% CI], 0.410 [0.400-0.415] vs. 0.280 [0.273-0.286], p < 0.01) and potassium (0.205 [0.199-0.211] vs. 0.083 [0.079-0.087], p < 0.01) were also significantly lower in the protocol group., Conclusion: The protocolized management of fluid in CRRT effectively prevented hypophosphatemia and hypokalemia by inducing excellent stability of serum phosphate and potassium levels., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Baeg, Jeon, Kang, Na, Cho, Kim, Yang, Chung, Lee, Huh, Suh, Kim, Kim and Jang.)

Background: No data is available on delirium prediction models in the cardiac intensive care unit (CICU), although preexisting delirium prediction models [PREdiction of DELIRium in ICu patients (PRE-DELIRIC) and Early PREdiction of DELIRium in ICu patients (E-PRE-DELIRIC)] were developed and validated based on a population admitted to the general intensive care unit (ICU). Therefore, we externally validated the usefulness of the PRE-DELIRIC and E-PRE-DELIRIC models and compared their predictive performance in patients admitted to the CICU., Methods: A total of 2,724 patients admitted to the CICU were enrolled between September 2012 and December 2018. Delirium was defined as at least one positive Confusion Assessment Method for the ICU (CAM-ICU) which was screened at least once every 8 h. The PRE-DELIRIC value was calculated within 24 h of CICU admission, and the E-PRE-DELIRIC value was calculated at CICU admission. The predictive performance of the models was evaluated by using the area under the receiver operating characteristic (AUROC) curve, and the calibration slope was assessed graphically by plotting., Results: Delirium occurred in 677 patients (24.8%) when the patients were assessed thrice daily until 7 days of the CICU stay. The AUROC curve for the prediction of delirium was significantly greater for PRE-DELIRIC values [0.84, 95% confidence interval (CI): 0.82-0.86] than for E-PRE-DELIRIC values (0.79, 95% CI: 0.77-0.80) [z score of -6.24 ( p < 0.001)]. Net reclassification improvement for the prediction of delirium increased by 0.27 (95% CI: 0.21-0.32, p < 0.001). Calibration was acceptable in the PRE-DELIRIC model (Hosmer-Lemeshow p = 0.170) but not in the E-PRE-DELIRIC model (Hosmer-Lemeshow p < 0.001)., Conclusion: Although both models have good predictive performance for the development of delirium, even in critically ill cardiac patients, the performance of the PRE-DELIRIC model might be superior to that of the E-PRE-DELIRIC model. Further studies are required to confirm our results and design a specific delirium prediction model for CICU patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Kim, Ko, Na, Chung, Choi, Kim, Park, Lee, Song, Choi, Hahn, Choi, Gwon and Yang.)

Background: Randomized clinical trials of spironolactone showed significant mortality reduction in patients with heart failure with reduced ejection fraction. However, its role in acute heart failure syndrome (AHFS) is largely unknown., Aim: To investigate the prescription characteristics, efficacy and safety of spironolactone in real-world patients with AHFS., Methods: 5,136 AHFS patients who survived to hospital discharge using a nationwide prospective registry in Korea were analyzed. The primary efficacy outcome was 3-year all-cause mortality., Results: Spironolactone was prescribed in 2,402 (46.8%) at discharge: <25 mg in 890 patients (37.1%), ≥25 mg, and <50 mg in 1,154 patients (48.0%), and ≥50 mg in 358 patients (14.9%). Patients treated with spironolactone had a lower proportion of chronic renal failure and renal replacement therapy during hospitalization and had lower serum creatinine level than those who did not. In overall patients, 3-year mortality was not different in both groups (35.9 vs. 34.5%, P = 0.279). The incidence of renal injury and hyperkalemia was 2.2% and 4.3%, respectively, at the first follow-up visit. The treatment effect of spironolactone on mortality was different across subpopulations according to LVEF. The use of spironolactone was associated with a significant reduction in 3-year morality in patients with LVEF ≤ 26% (33.8 vs. 44.3%, P < 0.001; adjusted HR 0.79, 95% CI 0.64-0.97, P = 0.023), but not in patients with LVEF > 26%., Conclusions: Although spironolactone was frequently used at lower doses in real-world practice, use of spironolactone significantly reduced 3-year mortality in patients with severely reduced LVEF with acceptable safety profile. However, our findings remain prone to various biases and further prospective randomized controlled studies are needed to confirm these findings., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Na, Youn, Lee, Jeon, Lee, Cho, Choi, Jeon, Lee, Kim, Kim, Hwang, Cho, Chae, Kang, Choi, Yoo, Kim, Oh and Baek.)