Shin Ok Koh

Association of body temperature and antipyretic treatments with mortality of critically ill patients with and without sepsis: multi-centered prospective observational study

IntroductionFever is frequently observed in critically ill patients. An independent association of fever with increased mortality has been observed in non-neurological critically ill patients with mixed febrile etiology. The association of fever and antipyretics with mortality, however, may be different between infective and non-infective illness.MethodsWe designed a prospective observational study to investigate the independent association of fever and the use of antipyretic treatments with mortality in critically ill patients with and without sepsis. We included 1,425 consecutive adult critically ill patients (without neurological injury) requiring > 48 hours intensive care admitted in 25 ICUs. We recorded four-hourly body temperature and all antipyretic treatments until ICU discharge or 28 days after ICU admission, whichever occurred first. For septic and non-septic patients, we separately assessed the association of maximum body temperature during ICU stay (MAXICU) and the use of antipyretic treatments with 28-day mortality.ResultsWe recorded body temperature 63,441 times. Antipyretic treatment was given 4,863 times to 737 patients (51.7%). We found that treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen independently increased 28-day mortality for septic patients (adjusted odds ratio: NSAIDs: 2.61, P = 0.028, acetaminophen: 2.05, P = 0.01), but not for non-septic patients (adjusted odds ratio: NSAIDs: 0.22, P = 0.15, acetaminophen: 0.58, P = 0.63). Application of physical cooling did not associate with mortality in either group. Relative to the reference range (MAXICU 36.5°C to 37.4°C), MAXICU ≥ 39.5°C increased risk of 28-day mortality in septic patients (adjusted odds ratio 8.14, P = 0.01), but not in non-septic patients (adjusted odds ratio 0.47, P = 0.11).ConclusionsIn non-septic patients, high fever (≥ 39.5°C) independently associated with mortality, without association of administration of NSAIDs or acetaminophen with mortality. In contrast, in septic patients, administration of NSAIDs or acetaminophen independently associated with 28-day mortality, without association of fever with mortality. These findings suggest that fever and antipyretics may have different biological or clinical or both implications for patients with and without sepsis.Trial registrationClinicalTrials.gov: NCT00940654

An evaluation of diaphragmatic movement by M-mode sonography as a predictor of pulmonary dysfunction after upper abdominal surgery.

BACKGROUND: Diaphragmatic dysfunction is a major factor in the etiology of postoperative pulmonary complications after upper abdominal surgery. M-mode ultrasonography is now an accepted qualitative method of assessing diaphragmatic motion in normal and pathological conditions. In this study, we evaluated whether diaphragmatic inspiratory amplitude (DIA) as measured by M-mode sonography can be a predictor of pulmonary dysfunction. METHODS: A prospective, single-center, single-unit, observational study was performed in 35 ASA physical status I and II nonsmoking patients undergoing open liver lobectomy. Diaphragmatic movements were assessed by M-mode sonography after a pulmonary function test preoperatively and on postoperative days (PODs) 1, 2, and 7. We measured the DIA (cm) during quiet, deep, and sniff breathing. RESULTS: After liver lobectomy, DIA during deep breathing and vital capacity (VC) showed significant reductions of 60% from their preoperative values on PODs 1 and 2 (P < 0.001). By POD 7, the variables recovered significantly, by 30% from the values on PODs 1 and 2 (P < 0.001). During deep breathing, DIA showed a significant correlation with VC (r = 0.839, P < 0.0001). The best cutoff values of DIA for detecting 30% and 50% decreases of VC from preoperative values, calculated by receiver operating characteristic analysis, were 3.61 and 2.41 cm, with sensitivity of 94% and 81% and specificity of 76% and 91%, respectively (P = 0.0001). Two patients showed postoperative diaphragmatic paralysis but did not complain of respiratory distress symptoms or need supplemental oxygen after being transferred to the general ward. CONCLUSIONS: DIA using M-mode sonography showed a linear correlation with VC measured by spirometry throughout the postoperative period. We conclude that using the M-mode sonographic technique at the bedside can be a practical way to investigate postoperative diaphragmatic dysfunction, and may also be an effective bedside screening method for diaphragmatic paralysis.

Higher dextrose delivery via TPN related to the development of hyperglycemia in non-diabetic critically ill patients

The beneficial effects of total parenteral nutrition (TPN) in improving the nutritional status of malnourished patients during hospital stays have been well established. However, recent randomized trials and meta-analyses have reported an increased rate of TPN-associated complications and mortality in critically ill patients. The increased risk of complications during TPN therapy has been linked to the development of hyperglycemia, especially during the first few days of TPN therapy. This retrospective study was conducted to determine whether the amount of dextrose from TPN in the 1st week in the intensive care unit (ICU) was related to the development of hyperglycemia and the clinical outcome. We included 88 non-diabetic critically ill patients who stayed in the medical ICU for more than two days. The subjects were 65 ± 16 years old, and the mean APACHE (Acute Physiology and Chronic Health Evaluation) II score upon admission was 20.9 ± 7.1. The subjects received 2.3 ± 1.4 g/kg/day of dextrose intravenously. We divided the subjects into two groups according to the mean blood glucose (BG) level during the 1st week of ICU stay: < 140 mg/dl vs ≥ 140 mg/dl. Baseline BG and the amount of dextrose delivered via TPN were significantly higher in the hyperglycemia group than those in the normoglycemia group. Mortality was higher in the hyperglycemia group than in the normoglycemia group (42.4% vs 12.8%, P = 0.008). The amount of dextrose from TPN was the only significant variable in the multiple linear regression analysis, which included age, APACHE II score, baseline blood glucose concentration and dextrose delivery via TPN as independent variables. We concluded that the amount of dextrose delivered via TPN might be associated with the development of hyperglycemia in critically ill patients without a history of diabetes mellitus. The amount of dextrose in TPN should be decided and adapted carefully to maintain blood glucose within the target range.

Acute kidney injury in critically ill patients with pandemic influenza A pneumonia 2009 in Korea: a multicenter study.

OBJECTIVES We assessed the incidence and clinical characteristics of acute kidney injury (AKI) in critically ill patients infected with pandemic influenza A (H1N1) and its effect on clinical outcomes. METHODS We conducted a multicenter, retrospective, observational study of patients with pandemic H1N1-related critical illness admitted to intensive care units (ICUs) of 28 tertiary or referral hospitals in South Korea between September 1, 2009, and February 28, 2010. Outcomes were AKI within 72 hours after ICU admission and 30-day mortality. Acute kidney injury was defined according to the Risk, Injury, Failure, Loss, and End-stage renal failure criteria. RESULTS Of the 221 patients, 50 (22.6%) developed AKI within 72 hours after ICU admission. Independent risk factors for AKI were age (odds ratio [OR], 1.05; P = .003), chronic kidney disease (OR, 14.82; P = .004), and Sequential Organ Failure Assessment score (OR, 1.45; P < .001). Age (OR, 1.04; P = .003), Sequential Organ Failure Assessment score (OR, 1.28; P = .012), state of immune suppression (OR, 4.09; P = .01), mechanical ventilation (OR, 18.24; P = .001), corticosteroid use (OR, 3.09; P = .007), and AKI (OR, 2.86; P = .035) were significantly associated with 30-day mortality. CONCLUSIONS A significant number of patients with H1N1-related critical illness developed AKI within 72 hours of ICU admission, and this early development of AKI was associated with 30-day mortality.

Markers of poor outcome in patients with acute hypoxemic respiratory failure.

PURPOSE This study described the acute hypoxemic respiratory failure (AHRF) population and identified potential modifiable markers of outcome. METHODS A prospective, multicenter study was performed in 22 intensive care units (ICUs). The clinical outcomes of patients with acute respiratory distress syndrome (ARDS) were compared to the outcomes in patients with non-ARDS AHRF, and a propensity score matched analysis was performed. RESULTS A total 837 patients with an arterial oxygen tension/fraction of inspired oxygen ratio (Pao2/Fio2) less than 300 mm Hg on ICU admission were included. Of these, 163 patients met the criteria defining ARDS, whereas the remaining 674 patients who had unilateral or no pulmonary opacities were classified as non-ARDS AHRF. Baseline Pao2/Fio2 ratio, thrombocytopenia, increased positive end-expiratory pressure (PEEP) were significantly associated with the 60-day mortality in hypoxemic respiratory failure after multivariate analysis. However, ARDS was not associated with increased 60-day mortality when independent predictors for the 60-day mortality and propensity score were controlled. In the case-control study, the 60-day mortality rate was 38.6% in the ARDS group and 32.3% in the non-ARDS AHRF group. In both patients with ARDS and non-ARDS AHRF, the mortality rate increased proportionally to a lower baseline Pao2/Fio2. CONCLUSION Lower baseline oxygenation (Pao2/Fio2) is a poor prognostic marker in acute hypoxemic respiratory failure.

Validation of SAPS3 admission score and its customization for use in Korean intensive care unit patients: a prospective multicentre study.

To externally validate the simplified acute physiology score 3 (SAPS3) and to customize it for use in Korean intensive care unit (ICU) patients.

The predictors for continuous renal replacement therapy in liver transplant recipients.

BACKGROUND Acute renal failure (ARF) after liver transplantation requiring continuous renal replacement therapy (CRRT) adversely affects patient survival. We suggested that postoperative renal failure can be predicted if a clinically simple nomogram can be developed, thus selecting potential risk factors for preventive strategy. METHODS We retrospectively reviewed the medical records of 153 liver transplant recipients from January 2008 to December 2011 at Severance Hospital, Yonsei University Health System, in Seoul, Korea. There were 42 patients treated with CRRT (20 and 22 patients received transplants from living and deceased donors, respectively) and 115 were not. Univariate and stepwise logistic multivariate analyses were performed. A clinical nomogram to predict postoperative CRRT application was constructed and validated internally. RESULTS Hepatic encephalopathy (HEP; odds ratio OR, 5.47), deceased donor liver donations (OR, 3.47), Model for End-Stage Liver Disease (MELD) score (OR, 1.09), intraoperative blood loss (L; OR, 1.16), and tumor (hepatocellular carcinoma) as the indication for liver transplantation (OR, 0.11) were identified as independent predictive factors for postoperative CRRT on multivariate analysis. A clinical prediction model constructed for calculating the probability of CRRT post-transplantation was 1.7000 × HEP + [-4.5427 + 1.2440 × (deceased donor) + 0.0830 × (MELD score) + 0.000149 × the amount of intraoperative bleeding (L) - 2.1785 × tumor]. The validation set discriminated well with an area under the curve (AUC) of 0.90 (95% confidence interval, 0.85-0.95). The predicted and the actual probabilities were calibrated with the clinical nomogram. CONCLUSIONS We developed a predictive model of postoperative CRRT in liver transplantation patients. Perioperative strategies to modify these factors are needed.

Impact of Eastern Cooperative Oncology Group Performance Status on hospital mortality in critically ill patients

INTRODUCTION This study evaluates the association between the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) and hospital mortality in general critically ill patients. MATERIALS AND METHODS This is a retrospective cohort study that analyzes prospective collected data from the Validation of Simplified acute physiology score 3 in Korean Intensive care unit study. The study population comprised patients who were consecutively admitted to participating intensive care units from July 1, 2010, to January 31, 2011. Univariate and multivariate logistic regression models were used to evaluate the effect of ECOG-PS on hospital mortality. RESULTS A total of 3868 patients were included in the analysis. There was a significant trend for increasing hospital mortality as the ECOG-PS grade became higher (P<.001). There was a trend of increasing adjusted odds ratio for hospital mortality, with grade 1 of PS 1.4 (95% confidence intervals [CIs], 1.0-1.8), grade 2 of PS 2.0 (95% CIs, 1.5-2.7), grade 3 of PS 2.9 (95% CIs, 2.1-4.1), and grade 4 of PS 2.5 (95% CIs, 1.6-3.9). Also, there was a significant difference in all grades. Subgroup analysis showed a trend of increasing hospital mortality regardless of the presence of cancer. CONCLUSION Preadmission PS, assessed with ECOG-PS in critically ill patients, has prognostic value in general critically ill patients.

The benefit of specialized team approaches in patients with acute kidney injury undergoing continuous renal replacement therapy: propensity score matched analysis.

IntroductionContinuous renal replacement therapy (CRRT) has been widely used in critically ill acute kidney injury (AKI) patients. Moreover, some centers operate a specialized CRRT team (SCT) composed of physicians and nurses, but few studies have yet determined the superiority of SCT control.MethodsA total of 334 among 534 patients in the original cohort, who started CRRT for severe AKI between August 2007 and September 2009 in Yonsei University Health System and were matched with a propensity score (PS), were divided into two groups based on SCT application. Moreover, we compared CRRT-related outcomes including down-time per day and lost time per filter-exchange between the two groups. The primary outcomes were 28- and 90-day all-cause mortality, and the secondary outcomes were the rates of renal function recovery at 28- and 90-day.ResultsThe down-time per day, lost time per filter-exchange, and red blood cell-transfused numbers during CRRT treatment were significantly lower after SCT approach compared with the group before SCT, while net ultrafiltration rate in the after SCT group was significantly higher compared to the before SCT group. During the study period, the 28- and 90-day all-cause mortality rates were significantly decreased after SCT application. Cox regression analysis revealed that 28- and 90-day all-cause mortality rates were significantly lower under SCT control, after adjusting for primary diagnosis, emergent surgical cases, Charlson Comorbidity Index and biochemical parameters. However, there were no significant differences in the rate of renal function recovery before and after SCT approach in CRRT.ConclusionsA well-organized CRRT team could be beneficial for clinical outcomes through improving quality of care in AKI patients requiring CRRT treatment in the ICU.

Body mass index and mortality in Korean intensive care units: a prospective multicenter cohort study.

Background The level of body mass index (BMI) that is associated with the lowest mortality in critically ill patients in Asian populations is uncertain. We aimed to examine the association of BMI with hospital mortality in critically ill patients in Korea. Methods We conducted a prospective multicenter cohort study of 3,655 critically ill patients in 22 intensive care units (ICUs) in Korea. BMI was categorized into five groups: <18.5, 18.5 to 22.9, 23.0 to 24.9 (the reference category), 25.0 to 29.9, and ≥30.0 kg/m2. Results The median BMI was 22.6 (IQR 20.3 to 25.1). The percentages of patients with BMI<18.5, 18.5 to 22.9, 23.0 to 24.9, 25.0 to 29.9, and ≥30.0 were 12, 42.3, 19.9, 22.4, and 3.3%, respectively. The Cox-proportional hazard ratios with exact partial likelihood to handle tied failures for hospital mortality comparing the BMI categories <18.5, 18.5 to 22.9, 25.0 to 29.9, and ≥30.0 with the reference category were 1.13 (0.88 to 1.44), 1.03 (0.84 to 1.26), 0.96 (0.76 to 1.22), and 0.68 (0.43 to 1.08), respectively, with a highly significant test for trend (p = 0.02). Conclusions A graded inverse association between BMI and hospital mortality with a strong significant trend was found in critically ill patients in Korea.