ABO blood types and sepsis mortality Itenov, Theis S.; Sessler, Daniel I.; Khanna, Ashish K. ...
Annals of intensive care,
04/2021, Letnik:
11, Številka:
1
Journal Article
Recenzirano
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Background
We aimed to determine if the ABO blood types carry different risks of 30-day mortality, acute kidney injury (AKI), and endothelial damage in critically ill patients with sepsis. This was a ...retrospective cohort study of three independent cohorts of critically ill patients from the United States and Scandinavia consisting of adults with septic shock. We compared the 30-day mortality across the blood types within each cohort and pooled the results in a meta-analysis. We also estimated the incidence of AKI and degree of endothelial damage, as measured by blood concentrations of soluble thrombomodulin and syndecan-1.
Results
We included 12,342 patients with severe sepsis. In a pooled analysis blood type B carried a slightly lower risk of 30-day all-cause mortality compared to non-blood type B (adjusted HR 0.88; 95%-CI 0.79–0.98;
p
= 0.02). There was no difference in the risk of AKI. Soluble thrombomodulin and syndecan-1 concentrations were lower in patients with blood type B and O compared to blood type A, suggesting less endothelial damage.
Conclusion
Septic patients with blood type B had less endothelial damage, and a small reduction in mortality. The exposure is, however, unmodifiable.
Aims and objectives
To describe the patient experience of ICU recovery from a longitudinal perspective by analysing follow‐up consultations at three time‐points.
Background
After a stay in the ...intensive care unit, patients risk physical and psychological problems during recovery. Follow‐up after intensive care has emerged to aid psychological recovery, and improve health‐related quality of life. More insight is needed into the mechanisms of intensive care recovery.
Design
A descriptive multicenter longitudinal qualitative design.
Methods
A subsample of 36 consultations with 12 patients strategically selected from a randomised controlled trial on intensive care recovery from 10 Danish intensive care units. Data were generated during an ICU recovery programme including three consultations (at 1–3, 4–5, 9–11 months). First consultation was face‐to‐face using patient photographs to aid memory. Second and third consultations were by telephone using reflection sheets to focus dialogue. Thematic analysis and narrative theory were used to explore mechanisms of recovery using audio‐recordings of consultations, patient photographs and reflection sheets as the sources of data.
Results
The basic narrative of recovery was ‘toward a trajectory of new orientation’. This narrative contained the chronological narratives of being ‘at death's door’, ‘still not out of the woods’ and ‘on the road to recovery’. The road to recovery was described as downhill, steady‐state or progressive. New orientation was obtained in steady‐state or progressive recovery.
Conclusions
This study provides a contemporary understanding of the process of intensive care recovery. Recovery evolves through narratives of mortal danger, risk of relapse and moving forward towards a new orientation in life.
Relevance to clinical practice
These findings enable health care professionals to understand what patients experience during stages of recovery. This is important to improve health care professionals in the assessment of long‐term outcome, and management of patients after intensive care.
Background
Delirium is highly prevalent in the intensive care unit (ICU) and is associated with high morbidity and mortality. The antipsychotic haloperidol is the most frequently used agent to treat ...delirium although this is not supported by solid evidence. The agents intervening against delirium in the intensive care unit (AID‐ICU) trial investigates the effects of haloperidol versus placebo for the treatment of delirium in adult ICU patients.
Methods
This protocol describes the secondary, pre‐planned Bayesian analyses of the primary and secondary outcomes up to day 90 of the AID‐ICU trial. We will use Bayesian linear regression models for all count outcomes and Bayesian logistic regression models for all dichotomous outcomes. We will adjust for stratification variables (site and delirium subtype) and use weakly informative priors supplemented with sensitivity analyses using sceptical priors. We will present results as absolute differences (mean differences and risk differences) and relative differences (ratios of means and relative risks). Posteriors will be summarised using median values as point estimates and percentile‐based 95% credibility intervals. Probabilities of any benefit/harm, clinically important benefit/harm and clinically unimportant differences will be presented for all outcomes.
Discussion
The results of this secondary, pre‐planned Bayesian analysis will complement the primary frequentist analysis of the AID‐ICU trial and facilitate a nuanced and probabilistic interpretation of the trial results.
OBJECTIVE:Use of antibiotics in critically ill patients may increase the risk of invasive Candida infection. The objective of this study was to determine whether increased exposure to antibiotics is ...associated with increased prevalence of invasive Candida infection.
DESIGN:Substudy using data from a randomized controlled trial, the Procalcitonin And Survival Study 2006–2010.
SETTING:Nine multidisciplinary ICUs across Denmark.
PATIENTS:A total of 1,200 critically ill patients.
INTERVENTION:Patients were randomly allocated to either a “high exposure” antibiotic therapy (intervention arm, n = 604) or a “standard exposure” guided by current guidelines (n = 596).
MEASUREMENTS AND MAIN RESULTS:Seventy-four patients met the endpoint, “invasive Candida infection,” 40 in the high exposure arm and 34 in standard exposure arm (relative risk = 1.2; 95% CI, 0.7–1.8; p = 0.52). Among medical patients in the high exposure arm, the use of ciprofloxacin and piperacillin/tazobactam was 51% and 75% higher than in the standard exposure arm; no difference in antibiotic exposure was observed between the randomized arms in surgical patients. Among medical intensive care patients, invasive Candida infection was more frequent in the high exposure arm (6.2%; 27/437) than in standard exposure arm (3.3%; 14/424) (hazard ratio = 1.9; 95% CI, 1.0–3.6; p = 0.05). Ciprofloxacin used at study entry independently predicted invasive Candida infection (adjusted hazard ratio = 2.1 1.1–4.1); the risk gradually increased with duration of ciprofloxacin therapysix of 384 in patients not exposed (1.6%), eight of 212 (3.8%) when used for 1–2 days (hazard ratio = 2.5; 95% CI, 0.9–7.3), and 31 of 493 (6.3%) when used for 3 days (hazard ratio = 3.8; 95% CI, 1.6–9.3; p = 0.002). Patients with any ciprofloxacin-containing antibiotic regimen the first 3 days in the trial had a higher risk of invasive Candida infection than did patients on any antibiotic regimen not containing ciprofloxacin (unadjusted hazard ratio = 3.7; 95% CI, 1.6–8.7; p = 0.003; adjusted hazard ratio, 3.4; 95% CI, 1.4–8.0; p = 0.006).
CONCLUSIONS:High exposure to antibiotics is associated to increased risk of invasive Candida infection in medical intensive care patients. Patients with ciprofloxacin-containing regimens had higher risk of invasive Candida infection. Other antibiotics, such as meropenem, piperacillin/tazobactam, and cefuroxime, were not associated with such a risk.
Background
The AID‐ICU trial aims to assess the benefits and harms of haloperidol for the treatment of delirium in acutely admitted, adult intensive care unit (ICU) patients. This paper describes the ...detailed statistical analysis plan for the primary publication of results from the AID‐ICU trial.
Methods
The AID‐ICU trial is an investigator‐initiated, pragmatic, international, multicentre, randomized, blinded, parallel‐group trial allocating 1000 adult ICU patients with manifest delirium 1:1 to haloperidol or placebo. The primary outcome measure is days alive and out of hospital within 90 days post‐randomization. Secondary outcome measures are days alive without delirium or coma, serious adverse reactions (SARs) to haloperidol, use of escape medicine, days alive without mechanical ventilation, and mortality, health‐related quality‐of‐life measures and cognitive function 1‐year post‐randomization. Statistical analysis will be conducted in accordance with the current pre‐specified statistical analysis plan. One formal interim analysis will be performed. The primary outcome will be adjusted for stratification variables (site and delirium motor subtype) and compared between treatment groups using a likelihood ratio test described by Jensen et al A secondary analysis will be conducted with additional adjustment of the primary outcome for prognostic variables at baseline. The primary conclusion of the trial will be based on the intention‐to‐treat analysis of the primary outcome adjusted for stratification variables.
Conclusion
The AID‐ICU trial will provide important, high‐quality data on the benefits and harms of treatment with haloperidol in acutely admitted, adult patients with manifest delirium in the ICU.
ABSTRACTCritically ill patients with acute kidney injury (AKI) are heterogeneous on pathophysiology and prognosis. The role of endothelial damage in the pathogenesis of refractory AKI has not been ...clarified. The aim was to determine if biomarkers of endothelial damage, independently of the inflammatory insult on the kidney, can predict recovery of acute kidney injury.
METHODS:From the “Procalcitonin And Survival Study” multicenter intensive care unit cohort, followed for 28 days after admission, we included patients without chronic kidney disease, who survived >24 h after admission and with plasma samples at admission available for biomarker analysis. We defined AKI by the “Kidney DiseaseImproving Global Outcomes” guidelines and recovery of prior kidney function as alive for five consecutive days after admission with no need for renal replacement therapy and creatinine levels consistently below ×1.5 the level before admission. We adjusted models for age, gender, vasopressor treatment, mechanical ventilation and levels of creatinine, procalcitonin, platelets, and bilirubin at admission.
RESULTS:Of a total 213 with AKI at admission, 99 recovered prior kidney function during follow-up. Endothelial damage on admission, measured by Soluble Thrombomodulin (sTM), was the strongest predictor of a reduced chance of recovery of prior kidney function (sTM in the highest vs. three lower quartiles hazard ratio 0.39; 95% confidence interval 0.21–0.73, P = 0.003). In contrast, the degree of the initial inflammatory insult on the kidney, measured by neutrophil gelatinase-associated lipocalin (NGAL), failed to predict this outcome (NGAL in highest vs. three lower quartiles hazard ratio = 1.20; 95% CI 0.72–2.00; P = 0.48). Procalcitonin, a specific marker of bacterial infection, was also associated with the rate of recovery (PCT in highest vs. three lower quartiles hazard ratio = 0.59; 95% CI 0.36–0.98; P = 0.04).
CONCLUSION:AKI patients with high levels of sTM had a reduced chance of recovering prior renal function. Our findings support disintegration of the endothelium as a critical point in the pathogenesis of AKI that is refractory to treatment.
Relatives of intensive care patients are at risk of developing symptoms of anxiety, depression and posttraumatic stress resulting in reduced health-related quality of life. Recovery programmes for ...patients have been implemented, but their effect on relatives is uncertain.
To determine whether relatives benefit from a recovery programme intended for intensive care survivors.
A randomised controlled trial of 181 adult relatives: intervention group (n = 87), control group (n = 94).
Ten intensive care units in Denmark.
Primary outcome: health-related quality of life (HRQOL). Secondary outcomes: Sense of coherence (SOC), and symptoms of anxiety, depression and posttraumatic stress, compared to standard care at 12 months after intensive care discharge.
No difference in HRQOL between groups was observed at 12 months (mean difference in mental component summary score, 1.35 CI 95%: −3.13; 5.82, p = 0.55; and physical component summery score, 1.86 CI 95%: −1.88; 5.59, p = 0.33). No differences were found in secondary outcomes.
The recovery programme intended for intensive care survivors did not have an effect on the relatives. Future recovery programmes should be targeted to help both patient and family, and future research should be conducted on a larger scale to make conclusions with higher probability.
Introduction. The objective of this study is, among half-year intensive care survivors, to determine whether self-assessment of health can predict two-year mortality. Methods. The study is a ...prospective cohort study based on the Procalcitonin and Survival Study trial. Half-year survivors from this 1200-patient multicenter intensive care trial were sent the SF-36 questionnaire. We used both a simple one-item question and multiple questions summarized as a Physical Component Summary (PCS) and a Mental Component Summary (MCS) score. The responders were followed for vital status 730 days after inclusion. Answers were dichotomized into a low-risk and a high-risk group and hazard ratios (HR) with 95% confidence interval (CI) were calculated by Cox proportional hazard analyses. Conclusion. We found that self-rated health measured by a single question was a strong independent predictor of two-year all-cause mortality (HR: 1.8; 95% CI: 1.1–3.0). The multi-item component scores of the SF-36 also predicted two-year mortality (PCS: HR: 2.9; 95% CI 1.7–5.0) (MCS: HR: 1.9; 95% CI 1.1–3.4). These results suggest that self-rated health questions could help in identifying patients at excess risk. Randomized controlled trials are needed to test whether our findings represent causality.
We aimed to evaluate post-COVID-19 fatigue, change in functional capacity and health-related quality of life (HRQoL) eight months after discharge from hospital due to COVID-19.
A total of 83 patients ...(35 women) admitted to the Copenhagen University Hospital - North Zealand Hospital, Denmark, for COVID-19 during the period from March to June 2020 were evaluated eight months after discharge using validated questionnaires quantifying fatigue, HRQoL and post-COVID-19 functional status. Follow-up data were correlated with measures of pre-COVID-19 status (anthropometrics, comorbidities) and measures of severity of the acute infection.
A total of 22 (65%) women and 12 (26%) men reported excessive fatigue. In all, 20 women (67%) and 17 men (37%) reported decreased physical function. Female sex was associated with fatigue. Loss of physical function was associated with pre-COVID-19 presence of heart disease and absence of lung disease. Severity of the acute COVID-19 infection was not associated with fatigue or change in functional status. Fatigue and functional status were correlated with both generic HRQoL and lung disease-specific HRQoL.
Female sex was associated with a higher risk of fatigue eight months after hospitalisation with COVID-19 infection. Regarding loss of functional capacity after COVID-19, we found an apparently protective effect of pre-COVID-19 lung disease. Our findings underscore the urgent need for further research and the importance of evaluating those recovering from COVID-19 for symptoms of excessive fatigue and change in functional capacity irrespective of the severity of the initial infection.
none.
not relevant.
Objective: Intensive care unit (ICU) patients with acute kidney injury (AKI) who recover kidney function within 28 days experience less severe chronic kidney impairment and have increased long term ...survival. The aims of this study were to develop and validate a risk prediction model to identify these patients. Design: Observational study with development and validation of a risk prediction model. Setting: Nine academic ICUs in Denmark. Participants: Development cohort of critically ill patients with AKI at ICU admission from the Procalcitonin and Survival Study cohort (n = 568), validation cohort of adult patients with AKI admitted to two university hospitals in Denmark in 2012-13 (n = 766). Interventions: None. Main outcome measures: Recovery of kidney function was defined as living for 5 consecutive days with no renal replacement therapy and with creatinine plasma levels below 1.5-fold the levels determined before ICU admission. Results: A total of 266 patients (46.8%) recovered prior kidney function in the development cohort, and 453 patients (59.1%) in the validation cohort. The prediction model included elevation in creatinine, urinary output, sex and age. In the validation cohort, 69 patients (9.0%) had a predicted chance of recovery < 25%, and their observed rate of recovery was 21.5%. This observed rate of recovery was 81.7% among the 325 patients who had a predicted chance > 75%. The area under the receiver operations curves for predicting recovery in the validation cohort was 73.1%. Conclusion: We constructed and validated a simple model that can predict the chance of recovery from AKI in critically ill patients.
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