Aline Santin

Association between timing of intensive care unit admission and outcomes for emergency department patients with community-acquired pneumonia*

Objective:To compare the 28-day mortality and hospital length of stay of patients with community-acquired pneumonia who were transferred to an intensive care unit on the same day of emergency department presentation (direct-transfer patients) with those subsequently transferred within 3 days of presentation (delayed-transfer patients). Design:Secondary analysis of the original data from two North American and two European prospective, multicenter, cohort studies of adult patients with community-acquired pneumonia. Patients:In all, 453 non-institutionalized patients transferred within 3 days of emergency department presentation to an intensive care unit were included in the analysis. Supplementary analysis was restricted to patients without an obvious indication for immediate transfer to an intensive care unit. Interventions:None. Measurements and Main Results:The sample consisted of 138 delayed-transfer and 315 direct-transfer patients, among whom 150 (33.1%) were considered to have an obvious indication for immediate intensive care unit admission. After adjusting for the quintile of propensity score, delayed intensive care unit transfer was associated with an increased odds ratio for 28-day mortality (2.07; 95% confidence interval, 1.12–3.85) and a decreased odds ratio for discharge from hospital for survivors (0.53; 95% confidence interval, 0.39–0.71). In a propensity-matched analysis, delayed-transfer patients had a higher 28-day mortality rate (23.4% vs. 11.7%; p = 0.02) and a longer median hospital length of stay (13 days vs. 7 days; p < .001) than direct-transfer patients. Similar results were found after excluding the 150 patients with an obvious indication for immediate intensive care unit admission. Conclusions:Our findings suggest that some patients without major criteria for severe community-acquired pneumonia, according to the recent Infectious Diseases Society of America/American Thoracic Society consensus guideline, may benefit from direct transfer to the intensive care unit. Further studies are needed to prospectively identify patients who may benefit from direct intensive care unit admission despite a lack of major severity criteria for community-acquired pneumonia based on the current guidelines.

Risk stratification of early admission to the intensive care unit of patients with no major criteria of severe community-acquired pneumonia: development of an international prediction rule.

IntroductionTo identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3.MethodsUsing the original data from four North American and European prospective multicentre cohort studies of patients with CAP, we derived and validated a prediction rule for ICU admission on days 1 to 3 of emergency department (ED) presentation, for patients presenting with no obvious reason for immediate ICU admission (not requiring immediate respiratory or circulatory support).ResultsA total of 6560 patients were included (4593 and 1967 in the derivation and validation cohort, respectively), 303 (4.6%) of whom were admitted to an ICU on days 1 to 3. The Risk of Early Admission to ICU index (REA-ICU index) comprised 11 criteria independently associated with ICU admission: male gender, age younger than 80 years, comorbid conditions, respiratory rate of 30 breaths/minute or higher, heart rate of 125 beats/minute or higher, multilobar infiltrate or pleural effusion, white blood cell count less than 3 or 20 G/L or above, hypoxaemia (oxygen saturation < 90% or arterial partial pressure of oxygen (PaO2) < 60 mmHg), blood urea nitrogen of 11 mmol/L or higher, pH less than 7.35 and sodium less than 130 mEq/L. The REA-ICU index stratified patients into four risk classes with a risk of ICU admission on days 1 to 3 ranging from 0.7 to 31%. The area under the curve was 0.81 (95% confidence interval (CI) = 0.78 to 0.83) in the overall population.ConclusionsThe REA-ICU index accurately stratifies the risk of ICU admission on days 1 to 3 for patients presenting to the ED with CAP and no obvious indication for immediate ICU admission and therefore may assist orientation decisions.

A randomized, controlled clinical trial of ketoprofen for sickle-cell disease vaso-occlusive crises in adults

Vaso-occlusive crisis (VOC) is the primary cause of hospitalization of patients with sickle-cell disease. Treatment mainly consists of intravenous morphine, which has many dose-related side effects. Nonsteroidal antiinflammatory drugs have been proposed to provide pain relief and decrease the need for opioids. Nevertheless, only a few underpowered trials of nonsteroidal antiinflammatory drugs for sickle-cell VOC have been conducted, and conflicting results were reported. We conducted a phase 3, double-blind, randomized, placebo-controlled trial with ketoprofen (300 mg/day for 5 days), a nonselective cyclooxygenase inhibitor, for severe VOC in adults. A total of 66 VOC episodes were included. The primary efficacy outcome was VOC duration. The secondary end points were morphine consumption, pain relief, and treatment failure. Seven VOC episodes in each group were excluded from the analysis because of treatment failures. No significant between-group differences were observed for the primary outcome or the secondary end points. Thus, although ketoprofen was well-tolerated, it had no significant efficacy as treatment of VOC requiring hospitalization. These findings argue against its systematic use in this setting.

Outcomes of Early, Late, and No Admission to the Intensive Care Unit for Patients Hospitalized with Community-acquired Pneumonia

OBJECTIVES The objective was to compare outcomes associated with early, late, and no admission to the intensive care unit (ICU) for patients hospitalized with community-acquired pneumonia (CAP). METHODS This was a post hoc analysis of the original data from the Emergency Department Community-Acquired Pneumonia (EDCAP) and Pneumocom-1 prospective multicenter cohort studies of adult patients hospitalized with CAP. Propensity score-adjusted analysis was used to compare 28-day mortality and hospital length of stay (LOS) for 199, 144, and 2,215 patients with early (i.e., ICU admission on the day of emergency department [ED] presentation), late, and no ICU admission. RESULTS Unadjusted 28-day mortality rates were 13.1, 19.4, and 5.7% for early, late, and no ICU admissions, respectively (p < 0.001). After adjusting for quintile of propensity score, the odds of 28-day mortality were higher for late ICU admissions relative to early ICU admissions (odds ratio [OR] = 2.63; 95% confidence interval [CI] = 1.42 to 4.90), and no ICU admissions (OR = 3.40; 95% CI = 2.11 to 5.48), but did not differ between early and no ICU admissions (OR = 1.29; 95% CI = 0.79 to 2.09). The median hospital LOS was 10 days for early (interquartile range [IQR] = 7 to 18), 15 days for late (IQR 9 to 23), and 6 days (IQR 4 to 9) for no ICU admissions (p < 0.001). CONCLUSIONS This study suggests that late but not early admission to the ICU is associated with higher 28-day mortality for patients hospitalized with CAP. Patients admitted to the ICU have longer hospital LOS in comparison to those managed on the wards, particularly if they are admitted late to the ICU.

Elevation of cardiac troponin I during non-exertional heat-related illnesses in the context of a heatwave

IntroductionThe prognostic value of cardiac troponin I (cTnI) in patients having a heat-related illness during a heat wave has been poorly documented.MethodsIn a post hoc analysis, we evaluated 514 patients admitted to emergency departments during the August 2003 heat wave in Paris, having a core temperature >38.5°C and who had analysis of cTnI levels. cTnI was considered as normal, moderately elevated (abnormality threshold to 1.5 ng.mL-1), or severely elevated (>1.5 ng.mL-1). Patients were classified according to our previously described risk score (high, intermediate, and low-risk of death).ResultsMean age was 84 ± 12 years, mean body temperature 40.3 ± 1.2°C. cTnI was moderately elevated in 165 (32%) and severely elevated in 97 (19%) patients. One-year survival was significantly decreased in patients with moderate or severe increase in cTnI (24 and 46% vs 58%, all P < 0.05). Using logistic regression, four independent variables were associated with an elevated cTnI: previous coronary artery disease, Glasgow coma scale <12, serum creatinine >120 μmol.L-1, and heart rate >110 bpm. Using Cox regression, only severely elevated cTnI was an independent prognostic factor (hazard ratio 1.93, 95% confidence interval 1.35 to 2.77) when risk score was taken into account. One-year survival was decreased in patients with elevated cTnI only in high risk patients (17 vs 31%, P = 0.04).ConclusionscTnI is frequently elevated in patients with non-exertional heat-related illnesses during a heat wave and is an independent risk factor only in high risk patients where severe increase (>1.5 ng.mL-1) indicates severe myocardial damage.

Serum sodium abnormalities during nonexertional heatstroke: incidence and prognostic values ☆,☆☆,★

BACKGROUND Although heatstroke is often associated with dehydration, the clinical significance of serum sodium abnormalities in patients with heat-related illness during heat wave has been poorly documented. METHOD We evaluated 1263 patients (age, 82±15 years; body temperature, 40.1°C+1.2°C) admitted to emergency departments during the August 2003 heat wave in Paris, having a core temperature greater than 38.5°C and measurement of serum sodium concentrations. Patients were classified according to our previously described risk score of death. RESULTS Hyponatremia (<135 mmol/L) was reported in 409 (32%) and hypernatremia (>145 mmol/L) in 220 patients (17%). One-year survival was significantly decreased in patients with hypernatremia (45%; P=.004) but not in those with hyponatremia (58%; P=.86) as compared with patients with serum sodium concentration in the reference range (57%). Using Cox regression, only hypernatremia was an independent prognostic factor (hazard ratio, 1.35; 95% confidence interval, 1.09-1.36) when risk score was taken into account. Using logistic regression, 2 variables were independently associated with hyponatremia (heatstroke severity score and blood urea nitrogen-creatinine ratio<100). Conversely, 5 variables were independently associated with hypernatremia (living in an institution, dementia, serum creatinine>120 μmol/L, a blood urea nitrogen-creatinine ratio >100, and absence of long-term diuretic intake). CONCLUSIONS Serum sodium abnormalities are frequently observed in patients with a nonexertional heatstroke during heat wave; however, only hypernatremia should be considered as an independent risk factor of death. Rapid measurement of serum sodium concentration is mandatory to appropriately guide electrolyte resuscitation.

Severe community acquired pneumonia: what should we predict?

Several aspects relating to the definition of severe community acquired pneumonia (CAP) and the design of prediction tools need to be addressed prior to further attempts to predict severe CAP. What is the concept of severe CAP based on? CAP severity could be based on pathophysiological disorders that would allow physicians to objectively define severity. Alternatively, CAP severity could be based on treatment intensity, which would certainly facilitate its uptake and the development of clinical tools to assist physicians in decision-making. This second approach, which seems more clinically relevant, will be assumed for the rest of this letter. What are the most relevant criteria for severe CAP? Basically, there are two possibilities: admission to ICU or respiratory/circulatory support requirement [1]. The former criterion is often perceived as too vague as it remains a matter of individual judgment [2]. The second is less prone to subjectivity, but may be too restrictive, as intensive care benefit is not limited to patients that require vital support. However, one must keep in mind the final objective of developing prediction tools for severe CAP; in this context, the definition exclusively based on respiratory/hemodynamic support requirement is less restrictive. Therefore, consistent with Chalmers [3], we suggest keeping this second definition of CAP severity. At this point, several features regarding prediction of severe CAP may be considered. Given the increasing evidence that patients with incipient severe sepsis may benefit from intensive care and from early referral, this prediction would apply to CAP patients presenting to the emergency department with rapidly progressive pneumonia at high risk of developing organ failure but with no overt respiratory/hemodynamic distress [4]. Indeed, predicting what is obvious is of no value. In contrast, patients that are too sick to be eligible for ICU admission have to be excluded. Additionally, regardless of the 30-day risk of severe CAP after presentation to the emergency department, if the 7-day risk is extremely low, CAP patients could be hospitalized in the wards. By contrast, if the 7-day risk is high, physicians would likely want to provide intensive care. Therefore, the most effective prediction tool would ascertain the risk of severe CAP within a week of presentation and assist physicians in making the critical ICU admission decision [5]. It is time for the medical community to unequivocally define severe CAP with the aim of improving the efficiency of resource utilization and the effectiveness of management strategies for patients that present with moderately severe CAP.

Symptomatic travel associated pulmonary embolism: high severity does not imply poor long term prognosis

As air travel has become increasingly popular during the last two decades, the death of a 27-year-old woman in the Arrivals Hall at Heathrow Airport after a 20 h flight triggered an important number of medical investigations that aimed to clarify the epidemiology, physiopathology, and associated risk factors of the so-called ‘economy class syndrome’ in order to support the evaluation of preventive strategies. Indeed, given the large number of people travelling long distances around the world, strategies intended for travel-associated venous thrombo-embolism (VTE) prevention must reach a high level of scientific quality, demonstrating safety and high effecacy. Therefore, such strategies should primarily focus on those patients with the highest risk of serious adverse outcomes associated with travel-related VTE. Unfortunately, despite a large amount of medical literature, several important features related to this issue remain under debate, and preventive strategies are still poorly documented, and mostly based on general precautions that might be helpful and harmless in preventing deep vein thrombosis (DVT).1–3 Therefore, there is a great interest in identifying those patients with the highest risk of developing travel-associated VTE, namely those presenting with symptomatic pulmonary embolism (PE). Indeed, the risk to travellers has to be balanced against potential adverse events associated with more aggressive preventive strategies such as low molecular weight heparin. In this perspective, the study published by Lehmann et al. 4 has original features that have added important insights to our knowledge of travel-associated symptomatic PE, which is the most threatening and therefore the most clinically relevant category of VTE. The authors compared clinical characteristics and the long-term prognosis of two groups of patients referred to hospital for the treatment of travel-associated or non-travel-associated PE. In 1856, Virchow first reported that … *Corresponding author. Tel: +33 1 49 81 25 23, Fax: +33 1 49 81 29 87, Email: bertrand.renaud{at}hmn.aphp.fr