Category Archives: Original Research

Pediatric Critical Care Illness Severity Toolkit: Stata Commands for Calculation of Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction Scores

Razvan Azamfirei1,2, Colleen Mennie1, James C. Fackler1,3, Sapna R. Kudchadkar1,3,4

1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
2 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Pediatrics, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
4 Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA

DOI: 10.2478/jccm-2023-0033

Introduction: Illness severity scoring tools, such as PRISM III/IV, PIM-3, and PELOD-2, are widely used in pediatric critical care research. However, their application is hindered by complex calculation processes, privacy concerns with third-party online calculators, and challenges in accurate implementation within statistical packages.
Methods: We have developed a comprehensive, open-source toolkit for implementing the PIM-3, Simplified PIM-3, and PELOD-2 scores. The toolkit includes the pim3 and pelod2 commands and is compatible with Stata versions 12 and above. It features robust data validation, error messaging, a graphical interface, and support for SI and Imperial units. The toolkit’s accuracy was validated through unit testing and synthetic data, comparing results with existing implementations.
Results: In performance tests, the toolkit exhibited a median processing time of 21.82 seconds for PELOD-2, 14.06 seconds for PIM-3, and 9.74 seconds for Simplified PIM-3, when applied to datasets of 10,000,000 records. It consistently achieved 100% accuracy in both synthetic data tests and manual spot checks.
Conclusion: The toolkit decreases processing time and improves accuracy in calculating pediatric critical care severity scores such as PELOD-2, PIM-3, and Simplified PIM-3. Its application in large datasets and validation highlights its utility as a tool for streamlining pediatric critical care research.

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Neutrophil-to-Lymphocyte Ratio and Thrombocyte-to-Lymphocyte Ratio as a Predictor of Severe and Moderate/Mild Acute Respiratory Distress Syndrome Patients: Preliminary Results

Mihai Claudiu Pui1, Mihaela Butiulca1,2, Vlad Cehan1, Florin Stoica3,4, Alexandra Lazar1,2

1 Department of Anesthesiology and Intensive Care Medicine, Emergency County Hospital, Targu Mures, Romania
2 Department of Anesthesiology and Intensive Care Medicine, Faculty of General Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Internal Medicine, Emergency County Hospital, Targu Mures, Romania
4 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2024-0005

Introduction: Acute respiratory distress syndrome (ARDS) represents a major cause of mortality in the intensive care unit (ICU). The inflammatory response is escalated by the cytokines and chemokines released by neutrophils, therefore the search for quantifying the impact of this pathophysiological mechanism is imperative. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) are indicators of systemic inflammation, widely accessible, inexpensive, and uncomplicated parameters.
Methods: We conducted a prospective study between March 2023 and June 2023 on patients which presented Berlin criteria for the diagnosis of ARDS during the first 24 hours from admission in the ICU. We included 33 patients who were divided into two groups: one group of 11 patients with severe ARDS and the second group of 22 patients with moderate/mild ARDS. The study evaluated demographic characteristics, leukocyte, lymphocyte, neutrophil, and platelet counts, as well as NLR and PLR values from complete blood count, and severity scores ( APACHE II score and SOFA score). We investigated the correlation of NLR and PLR in the two main groups (severe and moderate/mild acute respiratory distress syndrome patients).
Results: For the NLR ratio statistically significant differences between the the two groups are noted: Severe ARDS 24.29(1.13-96) vs 15.67(1.69-49.71), p=0.02 For the PLR ratio, we obtained significant differences within the group presenting severe ARDS 470.3 (30.83-1427) vs. the group presenting mild/moderate ARDS 252.1 (0-1253). The difference between the two groups is statistically significant (0.049, p<0.05). The cut-off value of NLR resulted to be 23.64, with an Area Under the Curve (AUC) of 0.653 (95% CI: 0.43-0.88). The best cut-off value of PLR was performed to be 435.14, with an Area Under the Curve (AUC) of 0.645 (95% CI: 0.41-0.88).
Conclusion: Our study showed that NLR and PLR ratios 24 hours in patients with moderate/severe ARDS diagnosis can be a good predictor for severity of the disease. These biomarkers could be used in clinical practice due to their convenience, inexpensiveness, and simplicity of parameters. However, further investigations with larger populations of ARDS patients are necessary to support and validate these current findings.

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Simplified Diagnosis of Urosepsis by Emergency Ultrasound Combined with Clinical Scores and Biomarkers

Alice Nicoleta Dragoescu1, Petru Octavian Dragoescu1, Andreea Doriana Stanculescu2, Vlad Padureanu1, Dalia Dop1, Mihai Alexandru Radu1, Mirela Marinela Florescu1, Daniela Teodora Maria1, Dan Nicolae Florescu1, George Mitroi1

1 Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania
2 Faculty of Pharmacy, University of Medicine and Pharmacy of Craiova, Craiova, Romania

DOI: 10.2478/jccm-2024-0006

Background: Urosepsis is a life-threatening medical condition due to a systemic infection that originates in the urinary tract. Early diagnosis and treatment of urosepsis are critical to reducing mortality rates and preventing complications. Our study was aimed at identifying a fast and reliable method for early urosepsis diagnosis and severity assessment by combining prognostic scores such as SOFA and NEWS with ultrasound examination and serum markers PCT and NLR.
Methods: We performed a single-center prospective observational study in the Craiova Clinical Emergency Hospital. It initially analysed 204 patients admitted for sepsis of various origins in our hospital between June and October 2023. Those with urological conditions that were suspected to have urosepsis have been selected for the study so that finally 76 patients were included as follows: the severe cases with persistent hypotension requiring vasopressor were enrolled in the septic shock group (15 patients – 19.7%), while the rest were included in the sepsis group (61 patients – 80.3%). Mortality rate in our study was 10.5% (8/76 deaths due to sepsis).
Results: Both prognostic scores SOFA and NEWS were significantly elevated in the septic shock group, as were the sepsis markers PCT and NLR. We identified a strong significant positive correlation between the NEWS and SOFA scores (r = 0.793) as well as PCT and NLR (r=0.417). Ultrasound emergency evaluation proved to be similar to CT scan in the diagnosis of urosepsis (RR = 0.944, p=0.264). ROC analysis showed similar diagnostic performance for both scores (AUC = 0.874 for SOFA and 0.791 for NEWS), PCT and NLR (AUC = 0.743 and 0.717).
Conclusion: Our results indicate that an accurate and fast diagnosis of urosepsis and its severity may be accomplished by combining the use of simpler tools like emergency ultrasound, the NEWS score and NLR which provide a similar diagnosis performance as other more complex evaluations.

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Lower Free T3 Levels Linked to Poorer Outcomes in Chronic Obstructive Pulmonary Disease Patients with Acute Hypercapnic Respiratory Failure

Türkay Akbaş1, Harun Güneş2

1 Düzce University, School of Medicine, Düzce, Türkiye
2 Balıkesir University, School of Medicine, Balıkesir, Türkiye

DOI: 10.2478/jccm-2024-0002

Aim of the Study: Non-thyroidal illness syndrome (NTIS) is often observed in critically ill patients. This study aimed to examine thyroid hormone changes in patients with chronic obstructive pulmonary disease (COPD) experiencing acute hypercapnic respiratory failure (AHRF) and to evaluate the impact of these alterations on clinical outcomes.
Materials and Methods: This retrospective investigation involved 80 COPD patients (age 71.5±9.5 years; 57.5% male) admitted to the intensive care unit (ICU) due to AHRF. NTIS was identified when free triiodothyronine (fT3) levels were below the lower limit, and thyroid-stimulating hormone (TSH) and free thyroxine (fT4) levels were within the normal range or below the lower limits.
Results: NTIS was detected in 63.7% of the patients. Decreased fT3 levels were found in 36.3% of the patients, reduced T4 levels in 33.8%, and diminished TSH levels in 15%. Patients with low fT3 levels exhibited elevated C-reactive protein levels, white blood cell counts, and APACHE II scores, necessitated vasopressor infusion more frequently during their ICU stay, and had increased mortality. The in-hospital mortality rate was 28.8%. Logistic regression analysis revealed that fT3 level (odds ratio [OR]., 0.271; 95% confidence interval [CI]., 0.085-0.865; p=0.027), APACHE II score (OR, 1.155; 95% CI, 1.041-1.282; p=0.007), and vasopressor use (OR, 5.426; 95% CI, 1.439-20.468; p=0.013) were crucial predictors of in-hospital mortality.
Conclusions: A high prevalence of NTIS is observed in COPD patients with AHRF, with low fT3 levels frequently observed. The presence of lower levels of fT3 is associated with a greater severity of the disease and a significant prognostic indicator.

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Comparison of Critical Illness Score in Patients Admitted to Intermediate Care Units of a Tertiary Care Hospital: A Comparative Cross-Sectional Study from Karachi, Pakistan

Amber Sabeen Ahmed, Madiha Iqbal, Sher Muhammad Sethi, Sania Sabir, Aysha Almas

Aga Khan University Hospital, Karachi, Pakistan

DOI: 10.2478/jccm-2024-0003

Introduction: Intermediate care units (IMCUs) serve as step-up units for emergency department patients and as step-down units for critically ill patients transferred from intensive care units. This study compares four critical illness scores for assessment of acutely ill patients and their accuracy in predicting mortality in patients admitted to IMCU.
Methods: A comparative cross-sectional study on patients aged ≥18 admitted to IMCU of Aga Khan University Hospital from 2017 to 2019. All patients admitted to IMCU from the emergency room were included in the study. Patient’s record were reviewed for demographic data, physiological and laboratory parameters. Critical illness scores were calculated from these variables for each patient.
Results: A total of 1192 patients were admitted to the IMCU, of which 923 (77.4%) medical records were finally analyzed. The mean (SD) age of participants was 62 years (± 16.5) and 469 (50.8%) were women. The overall hospital mortality rate of patients managed in IMCU was 6.4% (59/923 patients). The median scores of APACHE II, SOFA, SAPS II and MEWS were 16 (IQR 11–21), 4 (IQR 2–6), 36 (IQR 30–53) and 3 (IQR 2-4) points respectively. AUC for SAPS II was 0.763 (95% CI: 0.71-0.81), SOFA score was 0.735 (95% CI: 0.68-0.79) and MEWS score was 0.714 (95% CI: 0.66-0.77). The lowest ROC curve was 0.584 (95% CI: 0.52-0.64) for APACHE II.
Conclusion: In conclusion, our study found that SAPS II, followed by SOFA and MEWS scores, provided better discrimination in stratifying critical illness in patients admitted to IMCU of a tertiary care hospital in Pakistan.

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Is Carboxyhaemoglobin an Effective Bedside Prognostic Tool for Sepsis and Septic Shock Patients?

Bianca‐Liana Grigorescu1, Oana Coman2, Anca Meda Văsieșiu3, Anca Bacârea4, Marius Petrișor2, Irina Săplăcan5, Raluca Ștefania Fodor1

1 Department of Anesthesia and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Department of Simulation Applied in Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Infectious Diseases, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
5 County Emergency Clinical Hospital, Targu Mures, Romania

DOI: 10.2478/jccm-2023-0031

Introduction: Proper management of sepsis poses a challenge even today, with early diagnosis and targeted treatment being the most important steps. Easy, cost-effective bedside tools are needed in order to pinpoint towards the outcome of sepsis or septic shock.
Aim of study: This study aims to find a correlation between Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) severity scores, the Neutrophil-Lymphocytes Ratio (NLR) and carboxyhaemoglobin (COHb) levels in septic or septic shock patients with the scope of establishing a bed side cost-effective prognostic tool.
Materials and methods: A pilot, prospective, observational, and ongoing study was conducted on 61 patients admitted with sepsis or septic shock according to the SEPSIS 3 Consensus definition. We followed clinical and paraclinical parameters on day 1 (D1) and day 5 (D5) after meeting the inclusion criteria.
Results: On D1 we found a statistically significant positive correlation between each severity score (p <0.0001), r = 0.7287 for SOFA vs. APACHE II with CI: 0.5841-0.8285, r = 0.6862 for SOFA vs. SAPS II with CI: 0.5251-0.7998 and r = 0.8534 for APACHE II vs. SAPS II with CI: 0.7663 to 0.9097. On D5 we observed similar results: a significant positive correlation between each severity score (p <0.0001), with r = 0.7877 for SOFA vs. APACHE II with CI: 0.6283 to 0.8836, r = 0.8210 for SOFA vs. SAPS II with CI: 0.6822 to 0.9027 and r = 0.8880 for APACHE II vs. SAPS II., CI: 0.7952 to 0.9401. Nil correlation was found between the severity scores, NLR and COHb on D1 and D5.
Conclusion: Cost-effective bedside tools to pinpoint towards the outcome of sepsis are yet to be found, however the positive correlation between the severity scores point out to a combination of such tools for prognosis prediction of septic or septic shock patients.

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Study of Biochemical Parameters as Predictors for Need of Invasive Ventilation in Severely Ill COVID-19 Patients

Azmat Kamal Ansari1, Anjali Pitamberwale2, Shabana Andleeb Ansari1, Tariq Mahmood3, Kirti Limgaokar4, Geeta Karki1, Lalit Singh1

1 Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
2 Enzene Biosciences, Pune, Maharashtra, India
3 Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India
4 Fergusson College, Pune, Maharashtra, India

DOI: 10.2478/jccm-2023-0030

Background: Though laboratory tests have been shown to predict mortality in COVID-19, there is still a dearth of information regarding the role of biochemical parameters in predicting the type of ventilatory support that these patients may require.
Methods: The purpose of our retrospective observational study was to investigate the relationship between biochemical parameters and the type of ventilatory support needed for the intensive care of severely ill COVID-19 patients. We comprehensively recorded history, physical examination, vital signs from point-of-care testing (POCT) devices, clinical diagnosis, details of the ventilatory support required in intensive care and the results of the biochemical analysis at the time of admission. Appropriate statistical methods were used and P-values < 0.05 were considered significant. Receiver operating characteristics (ROC) analysis was performed and Area Under the Curve (AUC) of 0.6 to 0.7, 0.7 to 0.8, 0.8 to 0.9, and >0.9, respectively, were regarded as acceptable, fair, good, and exceptional for discrimination.
Results: Statistically significant differences (p<0.05) in Urea (p = 0.0351), Sodium (p = 0.0142), Indirect Bilirubin (p = 0.0251), Albumin (p = 0.0272), Aspartate Transaminase (AST) (p = 0.0060) and Procalcitonin (PCT) (p = 0.0420) were observed between the patients who were maintained on non-invasive ventilations as compared to those who required invasive ventilation. In patients who required invasive ventilation, the levels of Urea, Sodium, Indirect bilirubin, AST and PCT were higher while Albumin was lower. On ROC analysis, higher levels of Albumin was found to be acceptable indicator of maintenance on non-invasive ventilation while higher levels of Sodium and PCT were found to be fair predictor of requirement of invasive ventilation.
Conclusion: Our study emphasizes the role of biochemical parameters in predicting the type of ventilatory support that is needed in order to properly manage severely ill COVID-19 patients.

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Limitation of Non-Beneficial Interventions and their Impact on the Intensive Care Unit Costs

Sotiria Koutsouki1, Dimitrios Kosmidis2, Eva-Otilia Nagy3, Alexandra Tsaroucha4, Georgios Anastasopoulos5, Ioannis Pnevmatikos6, Vasileios Papaioannou7

1 General Hospital of Kavala, Kavala, Greece
2 Nursing Department, International Hellenic University, Didymoteicho, Greece
3 General Hospital of Kavala, Kavala, Greece
4 Postgraduate program on Bioethics, Laboratory of Bioethics, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
5 Medical Informatics Laboratory, Democritus University of Thrace, Alexandroupolis, Greece
6 Faculty of Medicine, University of Cyprus, Lefkosia, Cyprus
7 Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece

DOI: 10.2478/jccm-2023-0028

Introduction: Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients’ clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence. Aim of the study: To explore decisions to limit non-beneficial life support interventions, their correlation with patients’ clinical data, and their effect on the cost of care in the ICU.
Material and Methods: We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019-2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (ΝΒΙs), and economic data. Comparisons were made between patients with and without limitation decisions.
Results: NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p<0,001), greater disease severity score (APACHE IV, 71 vs. 50; p<0,001), longer length of stay (7d vs. 4.5d; p<0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p<0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p<0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p<0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p<0.001).
Conclusions: Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.

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Total Psoas Area and Psoas Density Assessment in COVID-19 Patients Using CT Imaging – Could Muscle Mass Alteration During Intensive Care Hospitalization be Determined?

Oana Elena Branea1, Anca Gabriela Vlad2, Mihai Pui2, Diana Andreea Becica2, Mihai Emanuel Becica2, AnaMaria Romina Budeanu2, Razvan Gabriel Budeanu2, Florin Stoica1, Alexandra Elena Lazar1

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Targu Mures County Emergency Clinical Hospital, Romania

DOI: 10.2478/jccm-2023-0026

Background: Since its debut, as reported by the first published studies, COVID-19 has been linked to life-threatening conditions that needed vital assistance and admission to the intensive care unit. Skeletal muscle is a core element in an organism’s health due to its ability to keep energy balance and homeostasis. Many patients with prolonged hospitalization are characterized by a greater probability prone to critical illness myopathy or intensive care unit-acquired weakness.
Objective: The main aim of this study was to assess the skeletal muscle in a COVID-19 cohort of critically ill patients by measuring the psoas area and density.
Material and methods: This is a retrospective study that included critically ill adult patients, COVID-19 positive, mechanically ventilated, with an ICU stay of over 24 hours, and who had 2 CT scans eligible for psoas muscle evaluation. In these patients, correlations between different severity scores and psoas CT scans were sought, along with correlations with the outcome of the patients.
Results: Twenty-two patients met the inclusion criteria. No statistically significant differences were noticed regarding the psoas analysis by two blinded radiologists. Significant correlations were found between LOS in the hospital and in ICU with psoas area and Hounsfield Units for the first CT scan performed. With reference to AUC-ROC and outcome, it is underlined that AUC-ROC is close to 0.5 values, for both the psoas area and HU, indicating that the model had no class separation capacity.
Conclusion: The study suggested that over a short period, the psoas muscle area, and the psoas HU decline, for both the left and the right sight, in adult COVID-19 patients in ICU conditions, yet not statistically significant. Although more than two-thirds of the patients had a negative outcome, it was not possible to demonstrate an association between the SARS-COV2 infection and psoas muscle impairment. These findings highlight the need for further larger investigations.

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A Retrospective Cohort Study of Traumatic Brain Injury in Children: A Single-Institution Experience and Determinants of Neurologic Outcome

Merve Misirlioglu1, Faruk Ekinci2, Dincer Yildizdas2, Ozden Ozgur Horoz2, Hayri Levent Yilmaz3, Faruk Incecik4, Mazhar Ozsoy5, Ahmet Yontem2, Sevcan Bilen3, Sena Silay6

1 Department of Pediatric Intensive Care, Mersin University Faculty of Medicine, Mersin, Turkey
2 Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
3 Department of Pediatric Emergency, Cukurova University Faculty of Medicine, Adana, Turkey
4 Department of Pediatric Neurology, Cukurova University Faculty of Medicine, Adana, Turkey
5 Department of Neurosurgery, Cukurova University Faculty of Medicine, Adana, Turkey
6 Department of Pediatrics, Cukurova University Faculty of Medicine, Adana, Turkey

DOI: 10.2478/jccm-2023-0027

Introduction: Traumatic brain injury (TBI) has become a significant cause of death and morbidity in childhood since the elucidation of infectious causes within the last century. Mortality rates in this population decreased over time due to developments in technology and effective treatment modalities.
Aim of the study: This retrospective cohort study aimed to describe the volume, severity and mechanism of all hospital-admitted pediatric TBI patients at a university hospital over a 5-year period. Material and
Methods: This was a single-center, retrospective cohort study including 90 pediatric patients with TBI admitted to a tertiary care PICU. The patients’ demographic data, injury mechanisms, disease and trauma severity scores, initiation of enteral nutrition and outcome measures such as hospital stay, PICU stay, duration of mechanical ventilation, mortality, and Glasgow Outcome Scale (GOS) were also recorded. Late enteral nutrition was defined as initiation of enteral feeding after 48 hours of hospitalization.
Results: Of the 90 patients included in the cohort, 60% had mild TBI, 21.1% had moderate TBI and 18.9% had severe TBI. Their mean age was 69 months (3-210 months). TBI was isolated in 34 (37.8%) patients and observed as a part of multisystemic trauma in 56 (62.2%). The most commonly involved site in multisystemic injury was the thorax (33.3%). The length of hospitalization in the late enteral nutrition group was significantly higher than that in the early nutrition group, while the PICU stay was not significantly different between the two groups. The multiple logistic regression analysis found a significant relationship between GOS-3rd month and PIM3 score, the presence of diffuse axonal injury and the need for CPR in the first 24 h of hospitalization.
Conclusion: Although our study showed that delayed enteral nutrition did not affect neurologic outcome, it may lead to prolonged hospitalization and increased hospital costs. High PIM3 scores and diffuse axonal injury are both associated with worse neurologic outcomes.

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