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Background: Shock index (SI) is calculated as heart rate divided by systolic blood pressure. In the obstetric population, SI of ≥ 0.9 is associated with maternal adverse outcomes. Our primary aim was to investigate the association between SI and post-spinal hypotension in non-elective cesarean section. Methods: In this prospective, observational study, term parturient of ASA physical status II, and urgency categories 2 and 3, undergoing non-elective cesarean section with spinal anesthesia were enrolled. We performed univariable and multivariable logistic regression to explore the association between baseline SI (categorized as < 0.9 and ≥ 0.9) and hypotension after spinal anesthesia. The diagnostic ability of the baseline SI to predict post-spinal hypotension was assessed using ROC (receiver operating characteristics) curves. Results: Three hundred forty-two parturient were recruited, and among them, 335 were analyzed. One hundred fifty-five (46.27%) parturients developed post-spinal hypotension, and 114 (34.03%) reported post-delivery hypotension. Preoperative SI (adjusted odds ratio [AOR], 2.77; 95% CI, 1.15–6.66; p = 0.023) and thoracic sensory block height > 4 (AOR, 2.33; 95%CI, 1.14–4.76; p = 0.020) were associated with post-spinal hypotension. Preoperative SI (AOR, 4.34; 95%CI, 1.72–10.94; p = 0.002) and anxiety (AOR,1.22; 95%CI, 1.06–1.40; p = 0.004) were associated with post-delivery hypotension. Area under the ROC curve for SI alone in predicting hypotension before and after delivery was 0.53 (95%CI 0.49–0.57) and 0.56 (95%CI 0.51–0.60) respectively. However, the model performance as reflected by ROC curve for the multivariable logistic regression analysis was 0.623 for post-spinal hypotension and 0.679 for post-delivery hypotension, respectively. Conclusion: In parturients undergoing non-elective cesarean section, baseline SI ≥ 0.9 was associated with post-spinal and post-delivery hypotension. While the SI alone showed limited predictive power for post-spinal and post-delivery hypotension, integrating it with other risk factors improved the model's predictive ability. Trial registration: Registration number: NCT04692870. Date of registration: 05/01/2021. Website: https://clinicaltrials.gov. [ABSTRACT FROM AUTHOR]

Aim: This study was designed to investigate the association between Charlson Comorbidity Index (CCI) and in‐hospital mortality and other clinical outcomes among patients with hyperglycemic crises. Method: This retrospective cohort study was conducted using data from electric medical records. A total of 1668 diabetic patients with hyperglycemic crises from six tertiary hospitals met the inclusion criteria. CCI < 4 was defined as low CCI and CCI ≥ 4 was defined as high CCI. Propensity score matching (PSM) with the 1:1 nearest neighbour matching method and the caliper value of 0.02 was used to match the baseline characteristics of patients with high CCI and low CCI to reduce the confounding bias. In‐hospital mortality, ICU admission, hypoglycemia, hypokalemia, acute kidney injury, length of stay (LOS), and hospitalisation expense between low CCI and high CCI were compared and assessed. Univariate and multivariate regression were applied to estimate the impact of CCI on in‐hospital and other clinical outcomes. Outcome: One hundred twenty‐one hyperglycemic crisis (HC) patients died with a mortality rate of 7.3%. After PSM, compared with low CCI, patients with high CCI suffered higher in‐hospital mortality, ICU admission, LOS, and hospitalisation expenses. After multivariate regression, age (aOR: 1.12, 95% confidence interval [CI]: 1.06−1.18, p < 0.001), CCI(aOR: 4.42, 95% CI: 1.56−12.53, p = 0.005), uninsured (aOR: 22.32, 95% CI: 4.26−116.94, p < 0.001), shock (aOR: 10.57, 95% CI: 1.41−79.09, p = 0.022), mechanical ventilation (aOR: 75.29, 95% CI: 12.37−458.28, p < 0.001), and hypertension (aOR: 4.34, 95% CI: 1.37−13.82, p = 0.013) were independent risk factors of in‐hospital mortality of HC patients. Besides, high CCI was an independent risk factor for higher ICU Admission (aOR: 5.91, 95% CI: 2.31−15.08, p < 0.001), hypoglycemia (aOR: 2.19, 95% CI:1.01−4.08, p = 0.049), longer LOS (aOR: 1.23, 95% CI: 1.19−2.27, p = 0.021), and higher hospitalisation expense (aOR: 2089.97, 95% CI: 193.33−3988.61, p = 0.031) of HC patients. Conclusion: CCI is associated with in‐hospital mortality, ICU admission, hypoglycemia, LOS, and hospitalisation expense of HC patients. CCI could be an ideal indicator to identify, monitor, and manage chronic comorbidities among HC patients. [ABSTRACT FROM AUTHOR]

Background: The hemodynamic profile in multisystem inflammatory syndrome in children (MIS-C) has not been well described. Therefore, we conducted the study utilizing electrocardiometry (EC) to assess the hemodynamic characteristics in MIS-C patients presenting with shock. Subjects and Methods: This pilot prospective observational study was conducted in the pediatric intensive care unit of a tertiary care hospital. Children between 2 months and 18 years meeting the WHO criteria for MIS-C presenting with shock during second COVID-19 pandemic were included in the study. All patients underwent measurement of hemodynamic profile with EC for the initial 48 h of enrollment. Based on EC assessment at enrolment, the systemic vascular resistance index (SVRi) of 1000–1600 dyn s/ cm5 /m² was regarded as normal. The hemodynamic categorization was defined as vasodilatory shock in EC (VDEC) (SVRi <1000 dyn s/[cm5 /m² ]) and vasoconstrictive shock in EC (VCEC) (SVRi > 1600 dyn s/[cm5 /m² ]). Results: Thirty-one children met the WHO case definition of MIS-C during the study period. Sixteen children with shock were enrolled and studied. Clinically, 7 (43.75%) children had cold shock, whereas 9 (56.25%) had warm shock. The measured baseline (mean [standard deviation]) hemodynamic variables were cardiac index (CI) of 6 ± 1.41 L/min/m², stroke volume variation of 23% ±9.6%, SVRi of 954.75 ± 263.35 dyn s/(cm5 /m² ), and thoracic fluid content of 51.18 ± 17.26 ml. VDEC was the predominant manifestation (87.5%) based on EC. Conclusions: Vasodilatory shock was the predominant phenotype observed in critically ill children with MIS-C with shock by EC assessment. [ABSTRACT FROM AUTHOR]

Introduction: The usual methods of perfusion assessment in patients with shock, such as capillary refill time, skin mottling, and serial serum lactate measurements have many limitations. Veno-arterial difference in the partial pressure of carbon dioxide (PCO2 gap) is advocated being more reliable. We evaluated serial change in PCO2 gap during resuscitation in circulatory shock and its effect on ICU outcomes. Materials and methods: This prospective observational study included 110 adults with circulatory shock. Patients were resuscitated as per current standards of care. We recorded invasive arterial pressure, urine output, cardiac index (CI), PCO2 gap at ICU admission at 6, 12, and 24 hours, and various patient outcomes. Results: Significant decrease in PCO2 gap was observed at 6 h and was accompanied by improvement in serum lactate, mean arterial pressure, CI and urine output in (n = 61). We compared these patients with those in whom this decrease did not occur (n = 49). Mortality and ICU LOS was significantly lower in patients with low PCO2 gap, while more patients with high PCO2 gap required RRT. Conclusion: We found that a persistently high PCO2 gap at 6 and 12 h following resuscitation in patients with shock of various etiologies, was associated with increased mortality, need for RRT and increased ICU LOS. High PCO2 gap had a moderate discriminative ability to predict mortality. [ABSTRACT FROM AUTHOR]

Background: The use of a venoarterial extracorporeal membrane oxygenation (ECMO) in the postcardiotomy shock setting (PC-ECMO) can be life-saving. Risk stratification for patients under PC-ECMO is currently challenging. The aim of this study was to assess the discriminatory ability of the different available risk scores for mortality in PC-ECMO patients. Methods: Patients aged >18 years undergoing coronary artery bypass, valve surgery, or a combination of these procedures and implanted an ECMO for postcardiotomy shock between January 2017 and June 2022 in a single ELSO registered center were retrospectively included. The STS, Euroscore II, SAVE, modified SAVE, APACHE II, and VIS scores were compared for their discriminatory ability concerning weaning and 30-day survival. Results: During the study period, 7342 patients underwent coronary bypass or valve surgery, of whom 109 patients with PC-ECMO were included in the analysis. The Euroscore II and STS scores were not associated significantly with 30-day mortality, whereas the SAVE, the modified SAVE, APACHE II, and VIS scores significantly predicted 30-day mortality. The SAVE and the modified SAVE scores showed moderate discrimination ability with AUCs of 0.672 and 0.695, while the APACHE and VIS scores had a satisfactory discriminatory ability with AUCs of 0.727 and 0.844, respectively. Conclusion: Currently used risk scores for PC-ECMO patients do not provide satisfactory predictions for weaning and survival. VIS at the 24th hour can be a valuable parameter for risk analysis and prospective studies can investigate novel PC-ECMO risk scoring systems. [ABSTRACT FROM AUTHOR]

Background: Analyses of extensive, nationally representative databases indicate a rising prevalence of venous thromboembolism (VTE) among critically ill children. However, the majority of studies on childhood VTE have primarily concentrated on Caucasian populations in the United States and European countries. There is a lack of epidemiological studies on VTE in Chinese children. Methods: We conducted a retrospective cohort study of data from the Pediatric Intensive Care (PIC) database. Data were obtained and extracted by using Structured Query Language (SQL) and the administrative platform pgAdmin4 for PostgreSQL. Bivariate analyses were conducted in which categorical variables were analyzed by a chi-square test and continuous variables were analyzed by a Student's t-test. Separate multivariable logistic regressions were employed to investigate the associations between VTE and sociodemographic factors as well as clinical factors. Results: Our study included 12,881 pediatric patients from the PIC database, spanning the years 2010 to 2018. The incidence rate of pediatric VTE was 0.19% (24/12,881). The venous thrombotic locations were deep venous thrombosis extremities (n = 18), superior vena cava (n = 1), cerebral sinovenous (n = 1), and other deep venous thrombosis (n = 4). Univariate analysis showed that age, weight, shock, sepsis, cancer and vasopressor receipt were statistically significant risk factors for pediatric VTE (all p ≤ 0.05). After multivariable logistic regression analysis, only shock (aOR: 6.77, 95%CI: 1.33–34.73, p = 0.019) and admission for sepsis (aOR: 6.09, 95%CI: 1.76–21.09, p = 0.004) were statistically significant associated with pediatric VTE. Conclusions: In conclusion, data obtained from the Pediatric Intensive Care (PIC) database revealed a prevalence of VTE in pediatric patients of 0.19%. The most common location for venous thrombi was deep venous thrombosis (DVT) in the extremities. We identified that shock and sepsis were statistically significant factors associated with pediatric VTE. [ABSTRACT FROM AUTHOR]

Background: Suspected upper gastrointestinal bleeding (SUGIB) is a common issue during ICU stay. In the absence of specific guidelines on the indication and timing of esophagogastroduodenoscopy (EGD), there is substantial variability in EGD indication depending on accessibility and clinical presentation. This study aimed to investigate factors associated with the need for per-EGD hemostatic therapy and to create a score predicting therapeutic benefit of emergency bedside EGD in ICU patients with SUGIB. Methods: We conducted a retrospective study in our ICU to identify factors associated with the need for hemostatic procedure during EGD performed for SUGIB. From this observational cohort, we derived a score predicting the need for hemostasis during EGD, the SUGIBI score. This score was subsequently validated in a retrospective multicenter cohort. Results: Two hundred fifty-five patients not primarily admitted for GI bleeding who underwent a bedside EGD for SUGIB during their ICU stay were analyzed. The preeminent EGD indication were anemia (79%), melena (19%), shock (14%), and hematemesis (13%). EGD was normal in 24.7% of cases, while primary lesions reported were ulcers (23.1%), esophagitis (18.8%), and gastritis (12.5%). Only 12.9% of patients underwent hemostatic endotherapy during EGD. A SUGIBI score < 4 had a negative predictive value of 95% (91–99) for hemostatic endotherapy [AUC of 0.81; 0.75–0.91 (p < 0.0001)]. The SUGIBI score for predicting the need for an EGD-guided hemostatic procedure was next validated in a multicenter cohort with an AUC of 0.75 (0.66–0.85) (p < 0.0001), a score < 4 having a negative predictive value of 95% (92–97). Conclusions: Our study shows that the therapeutic usefulness of bedside emergency EGD for SUGIB in critically ill patients is limited to a minority of patients. The SUGIBI score should help clinicians stratify the probability of a therapeutic EGD. [ABSTRACT FROM AUTHOR]

Background: Patients with bacterial meningitis can be severely ill necessitating intensive care unit (ICU) treatment. Here, we describe clinical features and prognostic factors of adults with bacterial meningitis admitted to the ICU in a nationwide prospective cohort study. Methods: We prospectively assessed clinical features and outcome of adults (age > 16 years) with community-acquired bacterial meningitis included in the MeninGene study between March 1, 2006 and July 1, 2022, that were initially admitted to the ICU. We identified independent predictors for initial ICU admission and for unfavourable outcome (Glasgow Outcome Scale score between 1–4) by multivariable logistic regression. Results: A total of 2709 episodes of bacterial meningitis were included, of which 1369 (51%) were initially admitted to the ICU. We observed a decrease in proportion of patients being admitted to the ICU during the Covid-19 pandemic in 2020 (decreased to 39%, p = 0.004). Median age of the 1369 patients initially admitted to the ICU was 61 years (IQR 49–69), and the rates of unfavourable outcome (47%) and mortality (22%) were high. During the Covid-19 pandemic, we observed a trend towards an increase in unfavourable outcome. Prognostic factors predictive for initial ICU admission were younger age, immunocompromised state, male sex, factors associated with pneumococcal meningitis, and those indicative of systemic compromise. Independent predictors for unfavourable outcome in the initial ICU cohort were advanced age, admittance to an academic hospital, cranial nerve palsies or seizures on admission, low leukocyte count in blood, high C-reactive protein in blood, low CSF: blood glucose ratio, listerial meningitis, need for mechanical ventilation, circulatory shock and persistent fever. 204 of 1340 episodes (15%) that were initially not admitted to the ICU were secondarily transferred to the ICU. The rates of unfavourable outcome (66%) and mortality (30%) in this group were high. Conclusions: The majority of patients with community-acquired bacterial meningitis are admitted to the ICU, and the unfavourable outcome and mortality rates of these patients remain high. Patients that are initially admitted to non-ICU wards but secondarily transferred to the ICU also had very high rates of unfavourable outcome. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 outbreak presents challenges to the emergency care system. Advanced age is a risk factor formortality. This study aimed to investigate whether the shock index (SI) is an early pre- dictor of adverse outcomes in geriatric patients with COVID-19. Methods: Patients aged ≤ 60 yearswith COVID-19 betweenMay 1, 2021, and February 1, 2022,were in- cluded in a retrospective cohort study. These patients were divided into two groups based on ICU ad- mission. Variables were compared for the two groups. The receiver operating characteristic analysis of the SI and age--SI (ASI) was used to detect deteriorating outcomes early. Results: In total, 156 patients were included, and the mean age was 68.52 ± 7.25 years. ICU admission, intubation, andmortality were recorded in 46 (29.49%), 32 (20.51%), and 16 (10.26%) patients, respec- tively. Themean body weight, pulse rate, respiratory rate, pulse oximetry, SI, and ASI were significantly different between the two groups (p = 0.018, 0.032, 0.007, < 0.001, 0.004, and 0.007, respectively). CRP, LDH, ALT, ferritin, D-dimer, and sodiumlevels were significantly associated with ICU admission. Regard- ing ICU admission, intubation, and mortality, the areas under the curve (AUC) of the SI and ASI showed acceptable discrimination. The predictive power of the ASI was significantly higher than that of the SI for mortality (AUC difference, 0.088 ± 0.036 (95% CI 0.017--0.160); p = 0.016). Conclusion: The ASI is a useful triage tool for mortality prediction in geriatric patients with COVID-19. The SI and ASI can be used in conjunction with vital signs, oxygen saturation, and laboratory biomarkers for the early detection of ICU admission. [ABSTRACT FROM AUTHOR]

Background: Tissue oxygen saturation (StO2) decrease could appear earlier than lactate alteration. However, the correlation between StO2 and lactate clearance was unknown. Methods: This was a prospective observational study. All consecutive patients with circulatory shock and lactate over 3 mmol/L were included. Based on the rule of nines, a BSA (body surface area) weighted StO2 was calculated from four sites of StO2 (masseter, deltoid, thenar and knee). The formulation was as follows: masseter StO2 × 9% + (deltoid StO2 + thenar StO2) × (18% + 27%)/ 2 + knee StO2 × 46%. Vital signs, blood lactate, arterial and central venous blood gas were measured simultaneously within 48 h of ICU admission. The predictive value of BSA-weighted StO2 on 6-hour lactate clearance > 10% since StO2 initially monitored was assessed. Results: A total of 34 patients were included, of whom 19 (55.9%) had a lactate clearance higher than 10%. The mean SOFA score was lower in cLac ≥ 10% group compared with cLac < 10% group (11 ± 3 vs. 15 ± 4, p = 0.007). Other baseline characteristics were comparable between groups. Compared to non-clearance group, StO2 in deltoid, thenar and knee were significantly higher in clearance group. The area under the receiver operating curves (AUROC) of BSA-weighted StO2 for prediction of lactate clearance (0.92, 95% CI [Confidence Interval] 0.82-1.00) was significantly higher than StO2 of masseter (0.65, 95% CI 0.45–0.84; p < 0.01), deltoid (0.77, 95% CI 0.60–0.94; p = 0.04), thenar (0.72, 95% CI 0.55–0.90; p = 0.01), and similar to knee (0.87, 0.73-1.00; p = 0.40), mean StO2 (0.85, 0.73–0.98; p = 0.09). Additionally, BSA-weighted StO2 model had continuous net reclassification improvement (NRI) over the knee StO2 and mean StO2 model (continuous NRI 48.1% and 90.2%, respectively). The AUROC of BSA-weighted StO2 was 0.91(95% CI 0.75-1.0) adjusted by mean arterial pressure and norepinephrine dose. Conclusions: Our results suggested that BSA-weighted StO2 was a strong predictor of 6-hour lactate clearance in patients with shock. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Children experience high tuberculosis (TB)-related mortality but causes of death among those with presumptive TB are poorly documented. We describe the mortality, likely causes of death, and associated risk factors among vulnerable children admitted with presumptive TB in rural Uganda. METHODS: We conducted a prospective study of vulnerable children, defined as <2 years of age, HIV-positive, or severely malnourished, with a clinical suspicion of TB. Children were assessed for TB and followed for 24 weeks. TB classification and likely cause of death were assessed by an expert endpoint review committee, including insight gained from minimally invasive autopsies, when possible. RESULTS: Of the 219 children included, 157 (71.7%) were <2 years of age, 72 (32.9%) were HIV-positive, and 184 (84.0%) were severely malnourished. Seventy-one (32.4%) were classified as "likely tuberculosis" (15 confirmed and 56 unconfirmed), and 72 (32.9%) died. The median time to death was 12 days. The most frequent causes of death, ascertained for 59 children (81.9%), including 23 cases with autopsy results, were severe pneumonia excluding confirmed TB (23.7%), hypovolemic shock due to diarrhea (20.3%), cardiac failure (13.6%), severe sepsis (13.6%), and confirmed TB (10.2%). Mortality risk factors were confirmed TB (adjusted hazard ratio [aHR] = 2.84 [95% confidence interval (CI): 1.19-6.77]), being HIV-positive (aHR = 2.45 [95% CI: 1.37-4.38]), and severe clinical state on admission (aHR = 2.45 [95% CI: 1.29-4.66]). CONCLUSIONS: Vulnerable children hospitalized with presumptive TB experienced high mortality. A better understanding of the likely causes of death in this group is important to guide empirical management. [ABSTRACT FROM AUTHOR]

Background & Objective: Acute myocardial infarction (MI) is caused due to coronary artery occlusion and divided into two forms of ST-elevation (STEMI) and non-ST-elevation (NSTEMI) myocardial infarction. This study aimed to determine the success rate of treatment with primary PCI (percutaneous coronary intervention) versus thrombolysis in the establishment of perfusion and to evaluate the short-term complications caused by each method. Materials & Methods: In this prospective cohort study, 90 patients were selected for primary PCI treatment and 90 patients for thrombolytic treatment. Clinical data and basic demographic characteristics of the patients and cardiovascular risk factors were recorded. The success rate of coronary reperfusion by primary PCI and thrombolytic therapy was then determined by angiography and 90-minute ECG with resolution or improvement of chest pain. All patients were examined for any serious complications such as cerebrovascular accidents, shock, and heart failure for 30 days after treatment. Data were analyzed using SPSS ver. 20. Results: In the primary PCI group, 75.6% of the patients were males, and 24.4% were females, but in the thrombolytic group, 76.6% and 23.3% of the cases were males and females, respectively. The mean door-to-balloon time for PCI was 63.60 ± 23.92 and was 53.70 ±21.52 min in the thrombolytic group. Thrombolysis in myocardial infarction (TIMI) flow grade III and TIMI-II were the most frequent in primary PCI and thrombolytic groups, respectively. The odds ratio (OD) of mechanical MI and major arrhythmia in patients received the primary PCI compared to those received thrombolytic therapy was 0.24 and 0.66, respectively. Also, the OD of mortality in the primary PCI group was 2.12. Conclusion: Our findings suggest that in STEMI patients, the chances of short term complications such as post-MI mechanical complications, major arrhythmia, and bleeding requiring blood transfusion were lower in patients who were treated with primary PCI than those who received thrombolytic treatment. Also, the average hospitalization in CCU and hospital in the primary PCI group was lower than the thrombolytic group. [ABSTRACT FROM AUTHOR]

Background: The aim of the study was to evaluate the utility of lactate, central venous oxygen saturation (ScvO2), and the difference in venous and arterial CO2 partial pressures (delta pCO2) levels and their relationship with the prognosis of critically ill children with circulatory failure in the pediatric intensive care unit (PICU). Subjects and Methods: Thirty children with circulatory failure who were admitted to the PICU of a tertiary university hospital between January 15 and November 1, 2020, were evaluated in this prospective observational study. Lactate levels, ScVO2, and delta pCO2 levels were evaluated on admission and at hours 4, 12, and 24 (T0, T4, T12, T24) in the PICU. Results: The mortality of the children with circulatory failure was 30% (n = 9). Arterial and venous lactate levels were highly correlated at T0, T4, T12, T24 (P < 0.001; P < 0.001; P < 0.001; P < 0.001, respectively). Nonsurvivors had always higher arterial lactate levels (T0, T4, T12, T24) (P = 0.019, P = 0.007, P = 0.002, P = 0.0003, respectively) and higher delta pCO2 at T0 (P = 0.039) when compared with survivors. Receiver operating characteristic analysis showed that T0 arterial lactate levels (area under the curve [AUC] 0.788, P = 0.019), T24 arterial lactate (AUC 0.918, P < 0,001), and T0 delta pCO2 levels (AUC 0,741, P = 0.039) and were predictive of mortality. Conclusions: Lactate remains the most important marker of microcirculatory dysfunction in critically ill children with circulatory failure. Delta pCO2 may be an additional marker of microcirculatory dysfunction in critically ill children. [ABSTRACT FROM AUTHOR]

Purpose: The indication for pre-hospital endotracheal intubation (ETI) must be well considered as it is associated with several risks and complications. The current guidelines recommend, among other things, ETI in case of shock (systolic blood pressure < 90 mmHg). This study aims to investigate whether isolated hypotension without loss of consciousness is a useful criterion for ETI. Methods: The data of 37,369 patients taken from the TraumaRegister DGU® were evaluated in a retrospective study with regard to pre-hospital ETI and the underlying indications. Inclusion criteria were the presence of any relevant injuries (Abbreviated Injury Scale [AIS] ≥ 3) and complete pre-hospital management information. Results: In our cohort, 29.6% of the patients were intubated. The rate of pre-hospital ETI increased with the number of indications. If only one criterion according to current guidelines was present, ETI was often omitted. In 582 patients with shock as the only indication for pre-hospital ETI, only 114 patients (19.6%) were intubated. Comparing these subgroups, the intervention was associated with longer time on scene (25.3 min vs. 41.6 min; p < 0.001), higher rate of coagulopathy (31.8% vs. 17.2%), an increased mortality (8.2% vs. 11.5%) and higher standard mortality ratio (1.17 vs. 1.35). If another intubation criterion was present in addition to shock, intubation was performed more frequently. Conclusion: Decision making for pre-hospital intubation in trauma patients is challenging in front of a variety of factors. Despite the presence of a guideline recommendation, ETI is not always executed. Patients presenting with shock as remaining indication and subsequent intubation showed a decreased outcome. Thus, isolated shock does not appear to be an appropriate indication for pre-hospital ETI, but clearly remains an important surrogate of trauma severity and the need for trauma team activation. [ABSTRACT FROM AUTHOR]

We propose a dynamic production function of population health and mortality from birth onward. Our parsimonious model provides an excellent fit for the mortality and survival curves for primate and human populations since 1816. The model sheds light on the dynamics behind many phenomena documented in the literature. Simple extensions of the model can reproduce (1) the existence and evolution of mortality gradients across socioeconomic statuses documented in the literature, (2) nonmonotonic dynamic effects of in utero shocks, (3) persistent or scarring effects of wars, and (4) mortality displacement after large temporary shocks, such as extreme weather. [ABSTRACT FROM AUTHOR]

Background/Aim. Despite technological advances in diagnosis and treatment, in-hospital mortality with acute aortic dissection type B is still about 11%. The purpose of this study was to assess the risk factors for early and long-term adverse outcomes in patients with acute aortic dissection type B treated medically or with conventional open surgery. Methods. The present study included 104 consecutive patients with acute aortic dissection type B treated in our Center from January 1st, 1998 to January 1st, 2007. Patient demographic and clinical characteristics as well as in-hospital complications were reviewed. Univariate and multivariate testing was performed to identify the predictors of in-hospital (30-day) and late (within 9 years) mortality. Results. 92 (88.5%) patients were treated medically, while 12 (11.5%) patients with complicated acute aortic dissection type B were treated by open surgical repair. In-hospital complications occurred in 35.7% patients, the most often being acute renal failure (28%), hypotension/shock (24%), mesenteric ischemia (12%), and limb ischemia (8%). The in-hospital mortality rate was 15.7% and the 9-year mortality rate was 51.9%. Independent predictors of early mortality in patients with acute aortic dissection type B were uncontrolled hypertension (HR-20.69) and a dissecting aorta diameter >4.75 cm (HR-6.30). Independent predictors of late mortality were relapsing pain (HR-7.93), uncontrolled hypertension (HR-7.25), and a pathologic difference in arterial blood pressure (>20 mmHg) (HR-5.33). Conclusion. Knowledge of key risk factors may help with a better choice of treatment and mortality reduction in acute aortic dissection type B patients. [ABSTRACT FROM AUTHOR]

Background: Monitoring oxygen saturation in shocked patients is a challenging nursing procedure. Shock syndrome alters peripheral tissue perfusion and hinders peripheral capillary oxygen saturation (SpO2) measurements. Our study aimed to find a solution to this problem. The pharynx is expected to be an accurate SpO2 measurement site in shocked patients. We clinically evaluated the pharyngeal SpO2 measurements against the arterial oxygen saturation (SaO2) measurements. Methods: A prospective cohort research design was used. This study included 168 adult shocked patients. They were admitted to five intensive care units from March to December 2020 in an Egyptian hospital. A wrap oximeter sensor was attached to the posterior surface of an oropharyngeal airway (OPA) by adhesive tape. The optical component of the sensor adhered to the pharyngeal surface after the OPA insertion. Simultaneous pharyngeal peripheral capillary oxygen saturation (SpO2) and arterial oxygen saturation (SaO2) measurements were recorded. The pharyngeal SpO2 was clinically evaluated. Also, variables associated with the SpO2 bias were evaluated for their association with the pharyngeal SpO2 bias. Results: The pharyngeal SpO2 bias was − 0.44% with − 1.65 to 0.78% limits of agreement. The precision was 0.62, and the accuracy was 0.05. The sensitivity to detect mild and severe hypoxemia was 100%, while specificity to minimize false alarm of hypoxemia was 100% for mild hypoxemia and 99.4% for severe hypoxemia. None of the studied variables were significantly associated with the pharyngeal SpO2 bias. Conclusion: The pharyngeal SpO2 has a clinically acceptable bias, which is less than 0.5% with high precision, which is less than 2%. [ABSTRACT FROM AUTHOR]

Background: Children with multisystem inflammatory syndrome in children (MIS-C) often develop shock and require vasoactive agents. The vasoactive-inotropic score (VIS) is a potential scoring system to assess the amount of vasoactive agent support required. The study was conducted to correlate VIS at 6 and 12 h with the length of intensive care unit (ICU) stay and with COVID immunoglobulin G (IgG) antibody titers in cases of MIS-C with shock. Subjects and Methods: Demographic and clinical details were collected from patients with the diagnosis of MIS-C with shock requiring vasoactive agents. VIS was calculated at 6 and 12 h following initiation of the first inotropic/vasoactive agent. Results: Twenty-nine children admitted with the diagnosis of MIS-C who presented with shock or developed shock during hospital stay were the study population. On performing Spearman's correlation, a positive correlation was observed between COVID IgG titers and VIS at 6 h. There was no significant association between VIS and length of ICU stay. Conclusions: VIS had limited significance in predicting the length of ICU stay and the need for vasoactive agents required. [ABSTRACT FROM AUTHOR]

Objective. This study aimed to investigate the clinical effect of ultrasound-guided transradial catheterization (TRC) for ICU patients with shock. Methods. 120 shock patients registered in the ICU of our hospital from January 2019 to June 2022 were selected for prospective study. The control group (60 patients) were treated with palpation-guided TRC. The observation group was treated with ultrasound-guided TRC and was divided into the internal puncture group (internal TRC) and external puncture group (external TRC), with 30 cases in each. The first attempt success rate, total success rate, operation duration, complication, measurement of radial artery, and VAS scores were compared in these groups. Results. The success rate was higher in the observation group than in the control group (P < 0.05), and higher in the internal puncture group than in the external puncture group (P < 0.05). The first attempt success rate was significantly higher in the observation group than in the control group (P < 0.05), with no significant difference in between (P > 0.05). The number of attempts and operation duration were lower in the observation group than in the control group (P < 0.05), with significantly more operation duration in the internal puncture group than in the external puncture group (P < 0.05) and no significant difference in the number of attempts (both P > 0.05). The complication rate was significantly lower in the observation group than in the control group (P < 0.05) and there was no significant difference in between (P > 0.05). The radial artery diameter, cross-sectional area, and depth from the skin in the observation group were larger than those in the control group (P < 0.05) and there was no significant difference in between (P > 0.05). At 1, 6, 24, and 48 h after the surgery, the observation group showed lower VAS scores than the control group (P < 0.05). Conclusion. The ultrasound-guided TRC reduced the number of attempts, the complication rates, and the operation duration. For patients with shock, if Doppler ultrasound cannot detect blood flow, the success rate in the observation group was higher than that in the control group, and its advantage is worthy of promotion in severe patients. [ABSTRACT FROM AUTHOR]

Rationale: Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill. Objectives: To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest). Methods: INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019. Measurements and Main Results: A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02-1.03), higher heart rate (OR, 1.008; 95% CI, 1.004-1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98-0.99), lower oxygen saturation as measured by pulse oximetry/FiO2 before induction (OR, 0.998; 95% CI, 0.997-0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05-1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72-3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02-1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84-2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96-1.44) did not reduce the incidence of cardiovascular instability/collapse. Conclusions: Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse.Clinical trial registered with clinicaltrials.gov (NCT03616054). [ABSTRACT FROM AUTHOR]

Background Multisystem Inflammatory Syndrome in Children (MIS-C) is a post-infectious complication of SARS-CoV-2 infection with overlapping features of Kawasaki disease and toxic shock syndrome. In May 2020, a provincial multidisciplinary working group was established in anticipation of emerging cases following the first wave of SARS-CoV-2 infections. Methodology Our centre established a multidisciplinary working group for MIS-C cases in British Columbia. The group developed guidelines using the World Health Organization MIS-C case definition. Guidelines were updated using quality improvement methods as new reports and our local experience evolved. We included all children who were evaluated in person or had samples sent to our centre for MIS-C evaluation from May 2020 to April 2021. We prospectively collected patient demographics, clinical and laboratory characteristics, and treatment. Results Fifty-two children were included. Eleven were diagnosed as confirmed MIS-C. Ten of the 11 MIS-C cases presented with shock. Gastrointestinal and mucocutaneous involvement were also prominent. Common laboratory features included elevated C-reactive protein, D-dimer, troponin, and brain natriuretic peptide. Four out of 11 (36%) had myocardial dysfunction and 3/11 (27%) had coronary artery abnormalities. All 11 patients had evidence of SARS-CoV-2 infection. Ten out of 11 (91%) received intravenous (IV) immunoglobulin and IV corticosteroids. Conclusion Our provincial cohort of MIS-C patients were more likely to present with shock and cardiac dysfunction, require ICU admission, and be treated with corticosteroids compared to ruled out cases. Our working group's evolving process ensured children with features of MIS-C were rapidly identified, had standardized evaluation, and received appropriate treatment in our province. [ABSTRACT FROM AUTHOR]

Background: One in four older adults in the Emergency Department (ED) suffers from severe cognitive impairment, creating great difficulty for the emergency physicians who determine the urgency of their patients' condition, which informs decisions regarding discharge or hospitalization.Objective: Our objective was to determine whether modified shock index (MSI) can be a clinical mortality and hospitalization predictor when applied to older patients with dementia in the ED.Methods: Included in the research were all patients with dementia, > 65 years old, who arrived at the Soroka University Medical Center ED during 2014-2017. The population was divided into three groups according to their MSI score, calculated as heart rate/mean arterial pressure: MSI < 0.7; 0.7 > MSI < 1.3; and MSI > 1.3. We performed multivariable logistic regression as a predictor of death within 30 days, Cox analysis for number of days to death, and a negative binominal regression for predicting the number of admission days.Results: Included were 1437 patients diagnosed with dementia. Patients with an MSI > 1.3 vs. those with MSI < 0.7 had an odds ratio of 8.23 (95% confidence interval [CI] 4.64-4.54) for mortality within 30 days, increased mortality risk within 180 days (hazard ratio 4.42; 95% CI 2.64-7.41), and longer hospitalization duration (incidence rate ratio 1.8; 95% CI 1.32-2.45).Conclusions: High MSI scores were associated with high mortality rates and longer hospitalization duration for patients diagnosed with dementia who were > 65 years old. We suggest performing prospective studies utilizing the MSI score as an indicator in ED triage settings to classify patients with dementia by their severity of risk, to determine if this benefits health, minimizes expenses, and prevents unnecessary hospitalizations. [ABSTRACT FROM AUTHOR]

Objective  The study aimed to evaluate the impact of obesity on the management and outcomes of postpartum hemorrhage. Study Design  We conducted a retrospective cohort study of women who delivered at a tertiary care center between February 1, 2013 and January 31, 2014 and experienced a postpartum hemorrhage. Charts were reviewed for clinical and sociodemographic data, and women were excluded if the medical record was incomplete. Hemorrhage-related severe morbidity indicators included blood transfusion, shock, renal failure, transfusion-related lung injury, cardiac arrest, and use of interventional radiology procedures. Obese (body mass index [BMI] ≥ 30 kg/m 2) and nonobese women were compared. Data were analyzed using Chi-square, Student's t -test, Mann–Whitney U test, and linear regression where appropriate. The p -value <0.05 was significant. Results  Of 9,890 deliveries, 2.6% (n  = 262) were complicated by hemorrhage. Obese women were more likely to deliver by cesarean section (55.5 vs. 39.8%, p  = 0.016), undergo a cesarean after labor (31.1 vs. 12.2%, p  = 0.001), and have a higher quantitative blood loss (1,313 vs. 1,056 mL, p  = 0.003). Both groups were equally likely to receive carboprost, methylergonovine, and misoprostol, but obese women were more likely to receive any uterotonic agent (95.7 vs. 88.9%, p  = 0.007) and be moved to the operating room (32.3 vs. 20.4, p  = 0.04). There was no difference in the use of intrauterine pressure balloon tamponade, interventional radiology, or decision to proceed with hysterectomy. The two groups were similar in time to stabilization. There was no difference in the need for blood transfusion. Obese women required more units of blood transfused (2.2 ± 2 vs. 2 ± 5 units, p  = 0.023), were more likely to have any hemorrhage-related severe morbidity (34.1 vs. 25%, p  = 0.016), and more than one hemorrhage related morbidity (17.1 vs. 7.9, p  = 0.02). After controlling for confounding variables, quantitative blood loss, and not BMI was predictive of the need for transfusion. Conclusion  Despite similar management, obese women were more likely to have severe morbidity and need more units of blood transfused. Key Points Obese women were more likely to have a higher quantitative blood loss and require more units of blood transfused. Obese women were more likely to experience any hemorrhage-related severe morbidity. Although obese women were more likely to be moved to the operating room for intervention, the rates of intrauterine pressure balloon tamponade, interventional radiology or hysterectomy were the same for obese and non-obese women. [ABSTRACT FROM AUTHOR]

Objective: Patients intubated in the ED are at an increased risk of post‐intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction. Methods: This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre‐ and post‐intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre‐ and post‐intubation was the primary measure of haemodynamic stability. Results: From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre‐intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose‐dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9. Conclusion: Propofol was associated with post‐intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post‐intubation hypotension. [ABSTRACT FROM AUTHOR]

Background: Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets. Methods: Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI‐associated events (TIAEs), oxygen desaturation (SpO2 < 80%), and procedural success. A multivariable model identified factors associated with TIAEs in the ED. Results: A total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7–108] months) than that for ICU TIs (15 [3–91] months; p < 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = –1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = –0.3%, 95% CI = –2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = –3.4%, 95% CI = –5.9 to –0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs. Conclusions: While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED. [ABSTRACT FROM AUTHOR]

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Background: Perforated peptic ulcer (PPU) has been associated with substantially high incidence of morbidity and mortality. The aim of this study was to analyze the factors affecting the outcome of patients having perforated peptic ulcer undergoing surgical intervention. Materials and methods: Medical records of 112 patients with PPU who underwent emergency laparotomy between December 2014 and November 2016 were prospectively analyzed. Primary suture of the perforation and pedicled omentoplasty was done in all the patients. Data regarding patients was collected and correlated with the postoperative outcome. Results: The overall postoperative morbidity and mortality were 62.5% and 30.4%, respectively. On univariate analysis advanced age (≥ 60 years) [(p = 0.005), (OR = 3.6), (95% CI = 1.5–8.8)], pre-operative shock [(p < 0.001), (OR = 7.4), (95% CI = 2.6–21.0)], delayed presentation (> 24 h) [(p = 0.007), (OR = 4.0), (95% CI = 1.5–11.2)] and raised serum creatinine [(p < 0.001), (OR = 7.7), (95% CI = 3.1–19.0)] were found to be significantly associated with the post-operative morbidity. For mortality, advanced age (≥ 60 year) [(p < 0.001), (OR = 5.02), (95% CI = 2.1–11.9)], pre-operative shock [(p < 0.001), (OR = 19.3), (95% CI = 6.9–53.6)], comorbidity [(p = 0.03), (OR = 6.6), (95% CI = 1.2–35.7)] and raised serum creatinine [(p < 0.001), (OR = 13.1), (95% CI = 4.5–37.8)] were statistically significant factors. Multivariate analysis showed advanced age (≥ 60 years) (p = 0.05) and raised serum creatinine (p = 0.004) as significant factors for increased risk of post-operative morbidity. Advanced age (≥ 60 years), pre-operative shock and raised serum creatinine were found to be independent risk factors influencing post-operative mortality (p < 0.05). Conclusion: A thorough clinical evaluation, adequate resuscitation, sepsis control, addressing comorbidities and early access to hospital can reduce the risk morbidity and mortality in patients with PPU. [ABSTRACT FROM AUTHOR]

Purpose: The modified Trauma-Induced Coagulopathy Clinical Score (mTICCS) presents a new scoring system for the early detection of the need for a massive transfusion (MT). This easily applicable score was validated in a large trauma cohort and proven comparable to more established complex scoring systems. However, the inter-rater reliability of the mTICCS has not yet been investigated. Methods: Therefore, a dataset of 15 randomly selected and severely injured patients (ISS ≥ 16) derived from the database of a level I trauma centre (2010–2015) was used. Moreover, 15 severely injured subjects that received MT were chosen from the same databank. A web-based survey was sent to medical professionals working in the field of trauma care asking them to evaluate each patient using the mTICCS. Results: In total, 16 raters (9 residents and 7 specialists) completed the survey. Ratings from 15 medical professionals could be evaluated and led to an ICC of 0.7587 (95% Bootstrap confidence interval (BCI) 0.7149–0.8283). A comparison of working experience specific ICC (n = 7 specialists, ICC: 0.7558, BCI: 0.7076–0.8270; n = 8 residents, ICC: 0.7634, BCI: 0.7183–0.8335) showed no significant difference between the two groups (p = 0.67). Conclusion: In summary, reliability values need to be considered when making clinical decisions based on scoring systems. Due to its easy applicability and its almost perfect inter-rater reliability, even with non-specialists, the mTICCS might therefore be a useful tool to predict the early need for MT in multiple trauma. [ABSTRACT FROM AUTHOR]

Objective: (1) To derive reference values for the Shock Index (heart rate/systolic blood pressure) based on a large emergency department (ED) population of febrile children and (2) to determine the diagnostic value of the Shock Index for serious illness in febrile children.Design/setting: Observational study in 11 European EDs (2017-2018).Patients: Febrile children with measured blood pressure.Main Outcome Measures: Serious bacterial infection (SBI), invasive bacterial infection (IBI), immediate life-saving interventions (ILSIs) and intensive care unit (ICU) admission. The association between high Shock Index (>95th centile) and each outcome was determined by logistic regression adjusted for age, sex, referral, comorbidity and temperature. Additionally, we calculated sensitivity, specificity and negative/positive likelihood ratios (LRs).Results: Of 5622 children, 461 (8.2%) had SBI, 46 (0.8%) had IBI, 203 (3.6%) were treated with ILSI and 69 (1.2%) were ICU admitted. High Shock Index was associated with SBI (adjusted OR (aOR) 1.6 (95% CI 1.3 to 1.9)), ILSI (aOR 2.5 (95% CI 2.0 to 2.9)), ICU admission (aOR 2.2 (95% CI 1.4 to 2.9)) but not with IBI (aOR: 1.5 (95% CI 0.6 to 2.4)). For the different outcomes, sensitivity for high Shock Index ranged from 0.10 to 0.15, specificity ranged from 0.95 to 0.95, negative LRs ranged from 0.90 to 0.95 and positive LRs ranged from 1.8 to 2.8.Conclusions: High Shock Index is associated with serious illness in febrile children. However, its rule-out value is insufficient which suggests that the Shock Index is not valuable as a screening tool for all febrile children at the ED. [ABSTRACT FROM AUTHOR]

Background: Whole body ischemia and reperfusion injury after cardiac arrest leads to the massive inflammation clinically manifested in the post-cardiac arrest syndrome. Previous studies on the inflammatory effect on circulatory failure after cardiac arrest have either investigated a selected patient group or a limited part of the inflammatory mechanisms. We examined the association between cardiac arrest characteristics and inflammatory biomarkers, and between inflammatory biomarkers and circulatory failure after cardiac arrest, in an unselected patient cohort.Methods: This was a prospective study of 50 consecutive patients with out-of-hospital cardiac arrest. Circulation was invasively monitored from admission until day five, whereas inflammatory biomarkers, i.e. complement activation, cytokines and endothelial injury, were measured daily. We identified predictors for an increased inflammatory response, and associations between the inflammatory response and circulatory failure.Results: We found a marked and broad inflammatory response in patients after cardiac arrest, which was associated with clinical outcome. Long time to return of spontaneous circulation and high lactate level at admission were associated with increased complement activation (TCC and C3bc), pro-inflammatory cytokines (IL-6, IL-8) and endothelial injury (syndecan-1) at admission. These biomarkers were in turn significantly associated with lower mean arterial blood pressure, lower cardiac output and lower systemic vascular resistance, and increased need of circulatory support in the initial phase. High levels of TCC and IL-6 at admission were significantly associated with increased 30-days mortality.Conclusion: Inflammatory biomarkers, including complement activation, cytokines and endothelial injury, were associated with increased circulatory failure in the initial period after cardiac arrest. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Hemorrhage is a leading cause of early mortality following trauma. A massive transfusion protocol (MTP) to guide resuscitation while bleeding is definitively controlled may improve outcomes. Prompts to initiate massive transfusion (MT) include shock index (SI) and the Assessment of Blood Consumption (ABC) score. Objective: To compare SI with the ABC score for association with transfusion requirement, need for emergency hemorrhage interventions, and early mortality. Methods: A retrospective cohort analysis of trauma MTP activations at our Level I trauma center was conducted from January 1, 2012, to December 31, 2016. The study data were obtained from the Trauma Registry and the blood bank. An SI cutoff of 1.0 was chosen for comparison with the positive ABC score. Results: The study cohort included 146 patients. Shock index ≥ 1 had significant association with MT requirement (p =.002) whereas a positive ABC score did not (p =.65). More patients with SI ≥ 1 required bleeding control interventions (67% surgery, 47% interventional radiology) than patients having a positive ABC score (49% surgery, 29% interventional radiology). For geriatric patients who received MT, 65% had SI ≥ 1 but only 30% had a positive ABC score. Three-hour mortality following emergency department arrival was similar (60% SI ≥ 1, 62% positive ABC score). Conclusion: Shock index ≥ 1 outperformed a positive ABC score for association with MT requirement. Shock index is a simple tool registered nurses can independently utilize to anticipate MT. [ABSTRACT FROM AUTHOR]

Background: Circulatory failure frequently occurs after out-of-hospital cardiac arrest (OHCA) and is part of post-cardiac arrest syndrome (PCAS). The aim of this study was to investigate circulatory disturbances in PCAS by assessing the circulatory trajectory during treatment in the intensive care unit (ICU). Methods: This was a prospective single-center observational cohort study of patients after OHCA. Circulation was continuously and invasively monitored from the time of admission through the following five days. Every hour, patients were classified into one of three predefined circulatory states, yielding a longitudinal sequence of states for each patient. We used sequence analysis to describe the overall circulatory development and to identify clusters of patients with similar circulatory trajectories. We used ordered logistic regression to identify predictors for cluster membership. Results: Among 71 patients admitted to the ICU after OHCA during the study period, 50 were included in the study. The overall circulatory development after OHCA was two-phased. Low cardiac output (CO) and high systemic vascular resistance (SVR) characterized the initial phase, whereas high CO and low SVR characterized the later phase. Most patients were stabilized with respect to circulatory state within 72 h after cardiac arrest. We identified four clusters of circulatory trajectories. Initial shockable cardiac rhythm was associated with a favorable circulatory trajectory, whereas low base excess at admission was associated with an unfavorable circulatory trajectory. Conclusion: Circulatory failure after OHCA exhibits time-dependent characteristics. We identified four distinct circulatory trajectories and their characteristics. These findings may guide clinical support for circulatory failure after OHCA. Trial registration : ClinicalTrials.gov: NCT02648061 [ABSTRACT FROM AUTHOR]

Introduction: Shock is the leading cause of death in multi-trauma patients and must be detected at an early stage to improve prognosis. Many parameters are used to predict clinical condition and outcome in trauma. Computed tomography (CT) signs of hypovolemic shock in trauma patients are not clear yet, requiring further research. The flatness index of inferior vena cava (IVC) is a helpful method for this purpose.Methods: This is a prospective, cross-sectional study which included adult multi-trauma patients (>18 years) who were admitted to the emergency department (ED) and underwent a thoraco-abdominal CT from 2017 through 2018. The main objective of this study was to investigate whether the flatness index of IVC can be used to determine the hypovolemic shock at an early stage in multi-trauma patients, and to establish its relations with shock parameters. The patients' demographic features, trauma mechanisms, vitals, laboratory values, shock parameters, and clinical outcome within 24 hours of admission were recorded.Results: Total of 327 (229 males with an average age of 40.9 [SD = 7.93]) patients were included in the study. There was no significant difference in the flatness index of IVC within genders (P = .134) and trauma mechanisms (P = .701); however, the flatness index of IVC was significantly higher in hypotensive (systolic blood pressure [SBP] ≤90 mmHg and/or diastolic blood pressure [DBP] ≤60 mmHg; P = .015 and P = .019), tachycardic (P = .049), and hypoxic (SpO2 ≤%94; P <.001) patients. The flatness index of IVC was also higher in patients with lactate ≥ 2mmol/l (P = .043) and patients with Class III hemorrhage (P = .003). A positive correlation was determined between lactate level and the flatness index of IVC; a negative correlation was found between Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) with the flatness index of IVC (for each of them, P <.05).Conclusion: The flatness index of IVC may be a useful method to determine the hypovolemic shock at an early stage in multi-trauma patients. [ABSTRACT FROM AUTHOR]

Background: Knowledge of resistance patterns is essential to choose empirical treatment. We aimed to determine the risk factors for antibiotic-resistant microorganisms (ARM) in intraabdominal infections (IAI) and their impact on mortality. Methods: Retrospective cohort study of patients with bacteremia from IAI origin in a single hospital between January 2006 and July 2017. Results: A total of 1485 episodes were recorded, including 381 (25.6%) due to ARM. Independent predictors of ARM were cirrhosis (OR 2; [95% CI 1.15–3.48]), immunosuppression (OR 1.49; 1.12–1.97), prior ceftazidime exposure (OR 3.7; 1.14–11.9), number of prior antibiotics (OR 2.33; 1.61–3.35 for 1 antibiotic), biliary manipulation (OR 1.53; 1.02–2.96), hospital-acquisition (OR 2.77; 1.89–4) and shock (OR 1.48; 1.07–2). Mortality rate of the whole cohort was 11.1%. Age (OR 1.03; 1.01–1.04), cirrhosis (OR 2.32; 1.07–4.38), urinary catheter (OR 1.99; 1.17–3.38), ultimately (OR 2.28; 1.47–3.51) or rapidly (OR 13.3; 7.12–24.9) fatal underlying disease, nosocomial infection (OR 2.76; 1.6–4.75), peritonitis (OR 1.95, 1.1–3.45), absence of fever (OR 2.17; 1.25–3.77), shock (OR 5.96; 3.89–9.13), and an ARM in non-biliary infections (OR 2.14; 1.19–3.83) were independent predictors of 30-day mortality. Source control (OR 0.24; 0.13–0.44) and 2015–2017 period (OR 0.29; 0.14–0.6) were protective. Conclusion: Biliary manipulation and septic shock are predictors of ARM. The presence of an ARM from a non-biliary focus is a poor-prognosis indicator. Source control continues to be of paramount importance. [ABSTRACT FROM AUTHOR]

Background Evidence on risk for adverse outcomes from coronavirus disease 2019 (COVID-19) among pregnant women is still emerging. We examined the association between COVID-19 at delivery and adverse pregnancy outcomes, maternal complications, and severe illness, and whether these associations differ by race/ethnicity, and describe discharge status by COVID-19 diagnosis and maternal complications. Methods Data from 703 hospitals in the Premier Healthcare Database during March–September 2020 were included. Adjusted risk ratios (aRRs) overall and stratified by race/ethnicity were estimated using Poisson regression with robust standard errors. Proportion not discharged home was calculated by maternal complications, stratified by COVID-19 diagnosis. Results Among 489 471 delivery hospitalizations, 6550 (1.3%) had a COVID-19 diagnosis. In adjusted models, COVID-19 was associated with increased risk for acute respiratory distress syndrome (aRR, 34.4), death (aRR, 17.0), sepsis (aRR, 13.6), mechanical ventilation (aRR, 12.7), shock (aRR, 5.1), intensive care unit admission (aRR, 3.6), acute renal failure (aRR, 3.5), thromboembolic disease (aRR, 2.7), adverse cardiac event/outcome (aRR, 2.2), and preterm labor with preterm delivery (aRR, 1.2). Risk for any maternal complications or for any severe illness did not significantly differ by race/ethnicity. Discharge status did not differ by COVID-19; however, among women with concurrent maternal complications, a greater proportion of those with (vs without) COVID-19 were not discharged home. Conclusions These findings emphasize the importance of implementing recommended prevention strategies to reduce risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and further inform counseling and clinical care for pregnant women during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Tidal volume challenge pulse pressure variation (TVC-PPV) is considered one of the recent reliable dynamic indices of fluid responsiveness (FR); also, passive leg raising (PLR)-induced changes in cardiac output (CO) detected by echocardiography are considered a reliable reversible self-fluid challenge test; many patients share eligibility for both tests. Objectives: The study aimed to compare the sensitivity and specificity of both tests for the prediction of FR in mechanically ventilated patients with hemodynamic instability. Methods: We studied 46 patients. Hemodynamic parameters including PPV and CO (detected by velocity time integral (VTI) using echocardiography) recorded at tidal volume (VT) of 6 mL/kg/ideal body weight (IBW) in semi-recumbent position then recorded again after one-minute increase in TV from 6 to 8 mL/kg/IBW then recorded with PLR at TV of 6 mL/kg/IBW and finally with actual volume expansion in semi-recumbent position by 4 ml/kg bolus of crystalloid solution to define actual responders with increase of cardiac output of 15% or more. Results: Sixteen patients were responders, and thirty patients were nonresponders; responders had significant increase in PPV with TVC 6 to 8 ml/kg/IBW with best cutoff value of 3.5 with a sensitivity of 93.8% and a specificity of 93.9%. PLR test-induced changes in CO had a sensitivity of 93.9% and a specificity of 86.7% with statistically best cutoff value of 6.5% increase in CO, but sensitivity was 75% at cutoff value of 10% increase in CO. Other parameters like PPV, PPV changes with PLR test, and PPV changes with fluid expansion were less sensitive indicators. Conclusion: FR in patients with hemodynamic instability and mechanically ventilated with low tidal volume strategy can be efficiently predicted when PPV increases more than 3.5 with tidal volume challenge and when PLR induces 6.5% increase in CO monitored through VTI method by Doppler echocardiography, and both tests are equally reliable. [ABSTRACT FROM AUTHOR]

Introduction: Centhaquine (Lyfaquin®) showed significant safety and efficacy in preclinical and clinical phase I and II studies. Methods: A prospective, multicentric, randomized phase III study was conducted in patients with hypovolemic shock, systolic blood pressure (SBP) ≤ 90 mmHg, and blood lactate levels ≥ 2 mmol/L. Patients were randomized in a 2:1 ratio to the centhaquine group (n = 71) or the control (saline) group (n = 34). Every patient received standard of care (SOC) and was followed for 28 days. The study drug (normal saline or centhaquine 0.01 mg/kg) was administered in 100 mL of normal saline infusion over 1 h. The primary objectives were to determine changes (mean through 48 h) in SBP, diastolic blood pressure (DBP), blood lactate levels, and base deficit. The secondary objectives included the amount of fluids, blood products, and vasopressors administered in the first 48 h, duration of hospital stay, time in intensive care units, time on ventilator support, change in acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS), and the proportion of patients with 28-day all-cause mortality. Results: The demographics of patients and baseline vitals in both groups were comparable. The cause of hypovolemic shock was trauma in 29.4 and 47.1% of control group and centhaquine group patients, respectively, and gastroenteritis in 44.1 and 29.4%, respectively. Shock index (SI) and quick sequential organ failure assessment at baseline were similar in the two groups. An equal amount of fluids and blood products were administered in both groups during the first 48 h of resuscitation. A lesser amount of vasopressors was needed in the first 48 h of resuscitation in the centhaquine group. An increase in SBP from baseline was consistently higher up to 48 h (12.9% increase in area under the curve from 0 to 48 h [AUC0–48]) in the centhaquine group than in the control group. A significant increase in pulse pressure (48.1% increase in AUC0–48) in the centhaquine group compared with the control group suggests improved stroke volume due to centhaquine. The SI was significantly lower in the centhaquine group from 1 h (p = 0.032) to 4 h (p = 0.049) of resuscitation. Resuscitation with centhaquine resulted in a significantly greater number of patients with improved blood lactate (control 46.9%; centhaquine 69.3%; p = 0.03) and the base deficit (control 43.7%; centhaquine 69.8%; p = 0.01) than in the control group. ARDS and MODS improved with centhaquine, and an 8.8% absolute reduction in 28-day all-cause mortality was observed in the centhaquine group. Conclusion: Centhaquine is an efficacious resuscitative agent for treating hypovolemic shock. The efficacy of centhaquine in distributive shock is being explored. Trial Registration: Clinical Trials Registry, India; ctri.icmr.org.in, CTRI/2019/01/017196; clinicaltrials.gov, NCT04045327. [ABSTRACT FROM AUTHOR]

Objectives: To compare the incidence of healthcare-associated infections (HAI) and their outcomes between patients admitted to the ICU with sepsis and those admitted with non-sepsis diagnoses. Materials and methods: We performed a single-center, prospective, observational study of ICU patients at a tertiary level medical-surgical unit from April 2018 to October 2018. All patients admitted to the ICU with a length of stay (LOS) > 48 hours were included. Baseline data including demographics, co-morbidities, and severity of illness scores were collected. Index occurrence of HAI in all these patients was noted and data regarding organ support and patient outcomes were recorded. The incidence, complications, ICU LOS, and 30-day mortality of HAI were compared between the patients admitted to ICU originally with sepsis and non-sepsis diagnoses. Results: A total of 271 patients were evaluated in our study (N = 106 for the sepsis group and N = 165 for the non-sepsis group). No significant difference between the groups was found in the incidence of HAI (29.2% in sepsis group vs 24.4% in non-sepsis group; p = 0.07). Complications (acute kidney injury (AKI): 71 vs 45%; p = 0.01, shock: 81 vs 55%; p = 0.05, need for mechanical ventilation (MV): 30 vs 15%; p = 0.04) were more common in sepsis group compared to the non-sepsis group. The ICU LOS (12.2 ± 5.2 days vs 8.8 ± 2.05 days; p = 0.01) was significantly longer in the sepsis group. There was no significant difference in 30-day mortality between the groups (45 vs 25%; p = 0.07). Conclusions: The incidence of HAI seems to be similar between patients admitted with sepsis and non-sepsis diagnoses. However, patients admitted with sepsis develop higher rates of organ failure secondary to HAI and have a longer ICU LOS compared to patients admitted with non-sepsis diagnoses. The mortality rate of HAI did not differ between these two groups. [ABSTRACT FROM AUTHOR]

Background: The study aims to determine the variation of shock index (SI) before and after vaginal delivery and establish standard reference values in mothers who have not postpartum hemorrhage. Materials and Methods: A total of 2534 women who delivered vaginally were enrolled in the study. This prospective cross-sectional study was completed between November 2018 and September 2019 in our referral hospital. The exclusion criteria were anemia, cesarean delivery, maternal heart diseases, maternal thyroid disease, gestational hypertensive disorders, patients received epidural anesthesia, and less than a 34 week 0 day gestation, patients who had postpartum hemorrhage (PPH). We defined PPH as blood loss > 1000 ml at the time of delivery. All patients' SI (heart rate/systolic blood pressure) were measured prepartum and at the 30th minutes, 1st and 2nd-hour postpartum period. Shock index reference ranges were measured separately according to BMI, age, and parity groups. Results: 10136 SI values were assessed. The mean age ± SD was 27.28±5.95 years. The mean BMI ± SD was 24.89±4.87 kg/m2. The prepartum and postpartum 30th minutes, 1st hour, and 2nd hour mean shock index values were 0.76±0.07; 0.85±0.12; 0.84±0.12 and 0.81±0.12 respectively. The variation in SI values was significant by the Tukey test (P < 0.05). Conclusions: For SI to be a diagnostic character in the issue of PPH, reference values must be known, so in this study shock index reference percentile ranges and mean ± standard deviation of SI values were established. [ABSTRACT FROM AUTHOR]

Rationale: There are no prospective observational studies exploring the relationship between relative hypotension and adverse kidney-related outcomes among critically ill patients with shock.Objectives: To investigate the magnitude of relative hypotension during vasopressor support among critically ill patients with shock and to determine whether such relative hypotension is associated with new significant acute kidney injury (AKI) or major adverse kidney events (MAKE) within 14 days of vasopressor initiation.Methods: At seven multidisciplinary ICUs, 302 patients, aged ≥40 years and requiring ≥4 hours of vasopressor support for nonhemorrhagic shock, were prospectively enrolled. We assessed the time-weighted average of the mean perfusion pressure (MPP) deficit (i.e., the percentage difference between patients' preillness basal MPP and achieved MPP) during vasopressor support and the percentage of time points with an MPP deficit > 20% as key exposure variables. New significant AKI was defined as an AKI-stage increase of two or more (Kidney Disease: Improving Global Outcome creatinine-based criteria).Measurements and Main Results: The median MPP deficit was 19% (interquartile range, 13-25), and 54% (interquartile range, 19-82) of time points were spent with an MPP deficit > 20%. Seventy-three (24%) patients developed new significant AKI; 86 (29%) patients developed MAKE. For every percentage increase in the time-weighted average MPP deficit, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 5.6% (95% confidence interval, 2.2-9.1; P = 0.001) and 5.9% (95% confidence interval, 2.2-9.8; P = 0.002), respectively. Likewise, for every one-unit increase in the percentage of time points with an MPP deficit > 20%, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 1.2% (0.3-2.2; P = 0.008) and 1.4% (0.4-2.4; P = 0.004), respectively.Conclusions: Vasopressor-treated patients with shock are often exposed to a significant degree and duration of relative hypotension, which is associated with new-onset, adverse kidney-related outcomes.Study registered with Australian New Zealand Clinical Trial Registry (ACTRN 12613001368729). [ABSTRACT FROM AUTHOR]

Background: Fluid boluses aiming to improve the cardiac output and oxygen delivery are commonly administered in children with shock. An increased mean arterial pressure in addition to resolution of tachycardia and improved peripheral perfusion are often monitored as clinical surrogates for improvement in cardiac output. The objective of our study is to describe changes in cardiac index, mean arterial pressure, and their relationship to other indices of cardiovascular performance.Objective: The objective of our study is to describe changes in cardiac index, mean arterial pressure, and their relationship to other indices of cardiovascular performance.Design, Setting, Patients, and Interventions: We prospectively analyzed hemodynamic data from children in the cardiac ICU who received fluid bolus (10mL/kg of Ringers-Lactate over 30 min) for management of shock and/or hypoperfusion within 12h of cardiac surgery. Cardiac index responders and mean arterial pressure-responders were defined as CI ≥10% and mean arterial pressure ≥10%, respectively. We evaluated the gradient for venous-return (mean systemic filling pressure-central venous pressure), arterial load properties (systemic vascular resistance index and elastance index) and changes in vasopressor support after fluid bolus.Measurements and Main Results: Fifty-seven children between 1 month and 16 years (median Risk adjustment after congenital heart surgery Model for Outcome Surveillance in Australia and New Zealand score of 3.8 (interquartile range 3.7-4.6) received fluid bolus. Cardiac index-responsiveness and mean arterial pressure-responsiveness rates were 33% and 56%, respectively. No significant correlation was observed between changes in mean arterial pressure and cardiac index (r = 0.035, p = 0.79). Although the mean systemic filling pressure - central venous pressure and the number of cardiac index-responders after fluid bolus were similar, the arterial load parameters did not change in mean arterial pressure-nonresponders. Forty-three patients (75%) had a change in Vasoactive-Inotrope Score after the fluid bolus, of whom 60% received higher level of vasoactive support.Conclusions: The mean arterial pressure response to fluid bolus in cardiac ICU patients was unpredictable with a poor relationship between cardiac index-responsiveness and mean arterial pressure-responsiveness. Because arterial hypotension is frequently a trigger for administering fluids and changes in blood pressure are commonly used for tracking changes in cardiac output, we suggest a cautious and individualized approach to repeat fluid bolus based solely on lack of mean arterial pressure response to the initial fluid, since the implications include decreased arterial tone even if the cardiac index increases. [ABSTRACT FROM AUTHOR]

Objectives: Capillary refill time is a noninvasive method to assess tissue perfusion to determine shock status. Capillary refill time is defined as the time required to regain skin color after blanching pressure is applied. Although common methods to measure capillary refill time depend on clinicians' visual assessment, a new approach using a pulse oximeter waveform analysis exists, referred to as full finger reperfusion time. We aim to evaluate reproducibility and validity of the novel full finger reperfusion time measurement using clinicians' visual capillary refill time assessment as a reference standard.Design: Prospective observational study.Setting: PICUs and operating suites at a large academic children's hospital.Patients: Ninety-nine children 1-12 years old with various skin color tones.Interventions: Each child had 10 measurements, including five full finger reperfusion time and five clinician capillary refill time, alternating second and third digits.Measurements and Main Results: Eighteen children had prolonged capillary refill time (> 2 s) and four children with capillary refill time greater than 3 seconds. Four-hundred eighty-five data pairs were analyzed. Intraclass correlation coefficient of full finger reperfusion time within each patient was 0.76 (95% CI, 0.68-0.83), demonstrating good reproducibility. Correlation coefficient between full finger reperfusion time and clinician capillary refill time was moderate: r = 0.37 (p < 0.0001; 95% CI, 0.29-0.44) for the pairs and r = 0.52 (p < 0.0001; 95% CI, 0.36-0.65) for patient average. Bland-Altman plot showed a consistent difference between full finger reperfusion time and clinician capillary refill time (full finger reperfusion time 1.14 s longer). Weak association was found between force and full finger reperfusion time (β = -0.033 ± 0.016; 95% CI, -0.065 to -0.0016; p = 0.04), finger thickness (β = -0.20 ± 0.089; 95% CI, -0.37 to -0.19; p = 0.03), except for color tone (p = 0.31). Finger temperature was associated with full finger reperfusion time (β = -0.18 ± 0.041; 95% CI, -0.26 to -0.0999; p < 0.0001).Conclusions: Full finger reperfusion time demonstrated good reproducibility. Full finger reperfusion time showed moderate correlation with clinician capillary refill time. Full finger reperfusion time was 1.14 seconds longer than capillary refill time. Future studies should focus on the clinical value of full finger reperfusion time as a monitoring device for hemodynamics in critically ill children. [ABSTRACT FROM AUTHOR]

Objectives: To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality.Design: Multicenter prospective cohort study between September 2017 and February 2018.Settings: Thirty-four hospitals in the United States and Jordan.Patients: Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor.Interventions: None.Measurement and Main Results: Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18).Conclusions: The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about frailty that develops following critical illness. We sought to describe the prevalence of newly acquired frailty, its clinical course, and the co-occurrence of frailty with disability and cognitive impairment in survivors of critical illness.Design: Longitudinal prospective cohort study.Setting: Medical and surgical ICUs at five U.S. centers.Patients: Adult patients treated for respiratory failure and/or shock.Measurements and Main Results: We measured frailty with the Clinical Frailty Scale at baseline (i.e., study enrollment) and at 3 and 12 months postdischarge. We constructed alluvial diagrams to describe the course of frailty and Venn diagrams to describe the overlap of frailty with disability in activities of daily living and cognitive impairment. We included 567 participants a median (interquartile range) of 61 years old (51-70 yr old) with a high severity of illness (Acute Physiology and Chronic Health Evaluation II of 23). Frailty (Clinical Frailty Scale scores ≥ 5) was present in 135 of 567 (24%) at baseline, 239 of 530 (45%) at 3 months, and 163 of 445 (37%) at 12 months. Of those with frailty at 3- or 12-month follow-up, 61% were not frail at baseline. Transition to a worse frailty state occurred in 242 of 530 of patients (46%) between baseline and 3 months and in 179 of 445 of patients (40%) between baseline and 12 months. There were 376 patients with frailty, disability, or cognitive impairment at 3-month follow-up. Of these, 53 (14%) had frailty alone. At 12 months, 276 patients had frailty, disability, or cognitive impairment, 37 (13%) of whom had frailty alone.Conclusions: Frailty is common among survivors of critical illness. In the majority, frailty is newly acquired. Roughly one in seven had frailty without co-occurring disability or cognitive impairment. Studies to understand outcomes of frailty that develops as the result of a critical illness and to identify modifiable risk factors for this potentially reversible syndrome are needed. [ABSTRACT FROM AUTHOR]

Background. Shock is one of the causes of mortality in the intensive care unit (ICU). Traditionally, hemodynamics related to shock have been monitored by broad-spectrum devices with treatment guided by many inaccurate variables to describe the pathophysiological changes. Critical care ultrasound (CCUS) has been widely advocated as a preferred tool to monitor shock patients. The purpose of this study was to analyze and broaden current knowledge of the characteristics of ultrasonic hemodynamic pattern and investigate their relationship to outcome. Methods. This prospective study of shock patients in CCUS was conducted in 181 adult patients between April 2016 and June 2017 in the Department of Intensive Care Unit of West China Hospital. CCUS was performed within the initial 6 hours after shock patients were enrolled. The demographic and clinical characteristics, ultrasonic pattern of hemodynamics, and outcome were recorded. A stepwise bivariate logistic regression model was established to identify the correlation between ultrasonic variables and the 28-day mortality. Results. A total of 181 patients with shock were included in our study (male/female: 113/68). The mean age was 58.2 ± 18.0 years ; the mean Acute Physiology and Chronic Health Evaluation II (APACHE II score) was 23.7 ± 8.7 , and the 28-day mortality was 44.8% (81/181). The details of ultrasonic pattern were well represented, and the multivariate analysis revealed that mitral annular plane systolic excursion (MAPSE), mitral annular peak systolic velocity (S ′ -MV), tricuspid annular plane systolic excursion (TAPSE), and lung ultrasound score (LUSS) were the independent risk factors for 28-day mortality in our study, as well as APACHE II score, PaO2/FiO2, and lactate (p = 0.047 , 0.041, 0.022, 0.002, 0.027, 0.028, and 0.01, respectively). Conclusions. CCUS exam on admission provided valuable information to describe the pathophysiological changes of shock patients and the mechanism of shock. Several critical variables obtained by CCUS were related to outcome, hence deserving more attention in clinical decision-making. Trial Registration. The study was approved by the Ethics Committee of West China Hospital Review Board for human research with the following reference number 201736 and was registered on ClinicalTrials. This trial is registered with NCT03082326 on 3 March 2017 (retrospectively registered). [ABSTRACT FROM AUTHOR]

Introduction: Obstetric patients are a special group of patients whose management is challenged by concerns for fetal viability, altered maternal physiology, and diseases specific to pregnancy. Materials and methods: A prospective analysis of all obstetric patients admitted to the critical care department was done to assess reasons for transfer to the critical care unit (CCU) and the interventions required for management of these patients. Results: Between June 2013 and September 2017, obstetric admission comprised 95 women (5.9%) of the total critical care admissions. There were 77 patients (81.1%) who were discharged from the hospital and 18 patients (18.9%) died. In most of the cases, the primary reasons for shifting the patient to the CCU were severe preeclampsia with pulmonary edema (22.1%), eclampsia (8.4%), acute respiratory distress syndrome (ARDS) (14.7%), and hypovolemic shock in antepartum hemorrhage (APH) and postpartum hemorrhage (PPH) (10.5 and 13.7%, respectively). It was seen that 73 patients (76.8%) required ventilator support, 58 patients (57.4%) required vasopressor support, and intensive hemodynamic monitoring and blood/blood products were transfused in 55 patients (54.5%). The need for ventilator support was more in patients with a lower PaO2/FiO2 and a higher APACHE II score. Patients with a high severity of illness score and a lower PaO2/FiO2 had higher odds of requiring vasopressors. Low hemoglobin at the time of transfer to the CCU and a prolonged hospital stay were found to predict the need for blood transfusion. Conclusion: Obstetric patients are susceptible to critical illnesses but timely management improves the outcome of these young women. [ABSTRACT FROM AUTHOR]

Objectives: Delirium, a heterogenous syndrome, is associated with worse long-term cognition after critical illness. We sought to determine if duration of motoric subtypes of delirium are associated with worse cognition.Design: Secondary analysis of prospective multicenter cohort study.Setting: Academic, community, and Veteran Affairs hospitals.Patients: Five-hundred eighty-two survivors of respiratory failure or shock.Interventions: We assessed delirium and level of consciousness using the Confusion Assessment Method-ICU and Richmond Agitation Sedation Scale daily during hospitalization. We defined a day with hypoactive delirium as a day with positive Confusion Assessment Method-ICU and corresponding Richmond Agitation Sedation Scale score less than or equal to 0 and a day with hyperactive delirium as a day with positive Confusion Assessment Method-ICU and corresponding Richmond Agitation Sedation Scale score greater than 0. At 3 and 12 months, we assessed global cognition with the Repeatable Battery for the Assessment of Neurologic Status and executive function with the Trail Making Test Part B. We used multivariable regression to examine the associations between days of hypoactive and hyperactive delirium with cognition outcomes. We allowed for interaction between days of hypoactive and hyperactive delirium and adjusted for baseline and in-hospital covariates.Measurements and Results: Hypoactive delirium was more common and persistent than hyperactive delirium (71% vs 17%; median 3 vs 1 d). Longer duration of hypoactive delirium was associated with worse global cognition at 3 (-5.13 [-8.75 to -1.51]; p = 0.03) but not 12 (-5.76 [-9.99 to -1.53]; p = 0.08) months and with worse executive functioning at 3 (-3.61 [-7.48 to 0.26]; p = 0.03) and 12 (-6.22 [-10.12 to -2.33]; p = 0.004) months; these associations were not modified by hyperactive delirium. Hyperactive delirium was not associated with global cognition or executive function in this cohort.Conclusions: Longer duration of hypoactive delirium was independently associated with worse long-term cognition. Assessing motoric subtypes of delirium in the ICU might aid in prognosis and intervention allocation. Future studies should consider delineating motoric subtypes of delirium. [ABSTRACT FROM AUTHOR]

Introduction: Nontraumatic undifferentiated hypotension is one of the common and challenging critical presentations in the emergency department (ED) due to the difficulty in diagnosing the etiology of shock. In the present study, an attempt was made to test point-of-care ultrasound (PoCUS) as an early approach to improve the accuracy of diagnosis and to narrow the differentials in cases of nontraumatic undifferentiated hypotension. Materials and methods: This is a prospective explorative study conducted in the ED of a tertiary care hospital over a period of 18 months. A total of 100 patients were included in the study. All patients >18 years of age with systolic blood pressure <90 mm Hg with at least one sign or symptom of hypoperfusion were included in the study. Patients referred from another hospital as shock, history of trauma, and history suggestive of orthostatic hypotension and presented with symptomatic postural hypotension as the only chief complaint were excluded. All the patients who met the inclusion/exclusion criteria underwent detailed clinical and multi-organ PoCUS evaluation by two different observers. Assessment of the lungs, cardia, abdomen, aorta, inferior vena cava (IVC), and leg veins during the PoCUS examination was done. A third observer combined the clinical evaluation and the PoCUS findings. All patients were followed through for their final diagnosis at the time of discharge. First, the diagnosis after clinical evaluation alone was compared to the final diagnosis. Then the diagnoses based on the findings of PoCUS alone were compared with the final diagnosis. Last, the diagnosis obtained on combining the data of clinical evaluation with that of PoCUS was compared to the final diagnosis. The data were analyzed based on their reliability indices, accuracy, and the Cohen's kappa coefficient. Results: Diagnoses based on clinical evaluation alone and POCUS alone were found to be accurate in 45% and 47% of patients, respectively. But on combining the findings of clinical evaluation with PoCUS, the accuracy increased to 89%. The most common etiology of shock was found to be distributive shock present in 38% of patients with sepsis being the most common subtype. In patients with obstructive shock, combined clinical evaluation with PoCUS was in perfect agreement with Cohen's kappa coefficient (κ) = 1 and those with distributive shock were in substantial agreement with Cohen's kappa coefficient (κ) = 0717. The overall kappa correlation of the combined evaluation with PoCUS was 0.89, which shows an almost perfect agreement with the final diagnosis. Conclusion: This study demonstrates the accuracy and reliability of PoCUS as an easy and valuable bedside tool when added to the clinical evaluation. It helps in narrowing the differentials and thereby guiding early goal-directed therapy in nontraumatic, undifferentiated hypotension patients presenting to the ED. [ABSTRACT FROM AUTHOR]

Aim: To assess the accuracy of the passive leg raising (PLR) test to anticipate fluid responsiveness in critically ill children under age of 5 years. Materials and methods: A prospective observational study was conducted, in a university hospital pediatric intensive care unit from June 1, 2017, to January 30, 2018. Hemodynamic parameters including stroke volume using bedside transthoracic echocardiography were assessed at baseline I (45° semi-recumbent position), after PLR, at baseline II, and following fluid challenge. Changes in the stroke volume (delta SV) and in the cardiac index (CI) were recorded after PLR and fluid challenge. Findings: Delta SV of 10% after PLR was an excellent discriminator of the fluid responsiveness with an area under ROC (AUC) of 0.81 (95% CI 0.68-0.9) with a sensitivity of 65.38% and a specificity of 100%. The change in CI of 8.7% after PLR was a significant discriminator of fluid responsiveness with an AUC of 0.7 (95% CI 0.56-0.81) with 57.78% sensitivity and 91.67% specificity. Conclusion: Passive leg raising can identify nonresponders among seriously ill children under the age of 5 years but it cannot identify all responders with certainty. Clinical significance: Passive leg raising is reliable test in under 5 year-old-children if performed appropriately using bedside echocardiography for the measurement of its transient effect. [ABSTRACT FROM AUTHOR]