Tag Archives: critical illness

Evaluation of the Efficiency of the Newly Developed Needle in Emergency Room: A Single-Center Observational Study

DOI: 10.2478/jccm-2024-0025

Aim of the study: Peripheral intravascular catheter (PIVC) insertion is frequently performed in the emergency room (ER) and many failures of initial PIVC insertion occur. To reduce the failures, new needles were developed. This study aimed to investigate whether the use of the newly developed needle reduced the failure of initial PIVC insertion in the ER compared with the use of the existing needle.
Material and methods: This single-centre, prospective observational study was conducted in Japan between April 1, 2022, and February 2, 2023. We included consecutive patients who visited our hospital by ambulance as a secondary emergency on a weekday during the day shift (from 8:00 AM to 5:00 PM). The practitioners for PIVC insertion and assessors were independent. The primary and secondary outcomes were the failure of initial PIVC insertion and number of procedures, respectively. We defined the difficulty of titrating, leakage, and hematoma within 30 s after insertion as failures. To evaluate the association between the outcomes and the use of newly developed needles, we performed multivariate logistic regression and multiple regression analyses by adjusting for covariates.
Results: In total, 522 patients without missing data were analysed, and 81 (15.5%) patients showed failure of initial PIVC insertion. The median number of procedures (interquartile range) was 1 (1–1). Multivariate logistic regression analysis revealed no significant association between the use of newly developed PIVCs and the failure of initial PIVC insertion (odds ratio, 0.79; 95% confidence interval, [0.48–1.31]; p = 0.36). Moreover, multiple regression analysis revealed no significant association between the use of newly developed PIVCs and the number of procedures (regression coefficient, -0.0042; 95% confidence interval, [-0.065–0.056]; p = 0.89).
Conclusions: Our study did not show a difference between the two types of needles with respect to the failure of initial PIVC insertion and the number of procedures.

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

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

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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Family Burden of ICU Survivors and Correlations with Patient Quality of Life and Psychometric Scores – A Pilot Study

DOI: 10.2478/jccm-2022-0027

Introduction: Post intensive care syndrome (PICS) affects an increasing number of critical illness survivors and their families, with serious physical and psychological sequelae. Since little is known about the burden of critical illness on ICU survivor families, we conducted a prospective observational study aiming to assess this, and investigate correlations of the patients’ psychometric and health-related quality of life (HRQOL) scores with family burden.
Materials and Methods: Twenty-nine patients were evaluated in the presence of a family member. Participants were assessed with the use of validated scales for anxiety, depression, post-traumatic stress disorder, cognitive decline, and the family burden scale (FBS).
Results: High burden was present in 27.6% of family members. Statistically significant correlations were observed between the FBS score and trait anxiety, depression, and the physical and psychological components of HRQOL.
Conclusions: Our results suggest that family burden following critical illness is common, suggesting that its assessment should be incorporated in the evaluation of PICS-family in large observational studies.

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The Correspondence between Fluid Balance and Body Weight Change Measurements in Critically Ill Adult Patients

DOI: 10.2478/jccm-2020-0048

Introduction: Positive fluid status has been associated with a worse prognosis in intensive care unit (ICU) patients. Given the potential for errors in the calculation of fluid balance totals and the problem of accounting for indiscernible fluid losses, measurement of body weight change is an alternative non-invasive method commonly used for estimating body fluid status. The objective of the study is to compare the measurements of fluid balance and body weight changes over time and to assess their association with ICU mortality. Methods: This prospective observational study was conducted in the 34-bed multidisciplinary ICU of a tertiary teaching hospital in southern Brazil. Adult patients were eligible if their expected length of stay was more than 48 hours, and if they were not receiving an oral diet. Clinical demographic data, daily and cumulative fluid balance with and without indiscernible water loss, and daily and total body weight changes were recorded. Agreement between daily fluid balance and body weight change, and between cumulative fluid balance and total body weight change were calculated. Results: Cumulative fluid balance and total body weight change differed significantly among survivors and non survivors respectively, +2.53L versus +5.6L (p= 0.012) and -3.05kg vs -1.1kg (p= 0.008). The average daily difference between measured fluid balance and body weight was +0.864 L/kg with a wide interval: -3.156 to +4.885 L/kg, which remained so even after adjustment for indiscernible losses (mean bias: +0.288; limits of agreement between -3.876 and +4.452 L/kg). Areas under ROC curve for cumulative fluid balance, cumulative fluid balance with indiscernible losses and total body weight change were, respectively, 0.65, 0.56 and 0.65 (p= 0.14). Conclusion: The results indicated the absence of correspondence between fluid balance and body weight change, with a more significant discrepancy between cumulative fluid balance and total body weight change. Both fluid balance and body weight changes were significantly different among survivors and non-survivors, but neither measurement discriminated ICU mortality.

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Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis

DOI: 10.2478/jccm-2020-0009

Introduction: Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.
Aim: To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.
Methods: Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.
Results: Restricted/goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally-fed patients experience increased episodes of vomiting (p = <0.01) but are less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.
Conclusions: There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.

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Anemia in Intensive Care: A review of Current Concepts

DOI: 10.1515/jccm-2016-0017

Anemia in patients admitted to an intensive care unit is common and affects almost all critically ill patients. The intensivist is faced with the challenge of treating multifactorial etiologies, mainly bleeding and blood loss due to phlebotomy and decreased erythropoiesis. Red cell transfusion, the most common treatment for anemia, comes with associated risks, which may further reduce the chance of survival of these patients. The best evidence suggests the practice of restrictive RBC transfusion (transfusion at Hb<7 g/dl).
In this article, the etiopathogenesis of the anemia in critically ill is reviewed, and current opinion on the pros and cons of various management strategies are discussed with emphasize on restrictive transfusion policy.

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