So Yeon Lim

Early initiation of low-dose corticosteroid therapy in the management of septic shock: a retrospective observational study

IntroductionThe use of low-dose steroid therapy in the management of septic shock has been extensively studied. However, the association between the timing of low-dose steroid therapy and the outcome has not been evaluated. Therefore, we evaluated whether early initiation of low-dose steroid therapy is associated with mortality in patients with septic shock.MethodsWe retrospectively analyzed the clinical data of 178 patients who received low-dose corticosteroid therapy for septic shock between January 2008 and December 2009. Time-dependent Cox regression models were used to adjust for potential confounding factors in the association between the time to initiation of low-dose corticosteroid therapy and in-hospital mortality.ResultsThe study population consisted of 107 men and 71 women with a median age of 66 (interquartile range, 54 to 71) years. The 28-day mortality was 44% and low-dose corticosteroid therapy was initiated within a median of 8.5 (3.8 to 19.1) hours after onset of septic shock-related hypotension. Median time to initiation of low-dose corticosteroid therapy was significantly shorter in survivors than in non-survivors (6.5 hours versus 10.4 hours; P = 0.0135). The mortality rates increased significantly with increasing quintiles of time to initiation of low-dose corticosteroid therapy (P = 0.0107 for trend). Other factors associated with 28-day mortality were higher Simplified Acute Physiology Score (SAPS) 3 (P < 0.0001) and Sequential Organ Failure Assessment (SOFA) scores (P = 0.0007), dose of vasopressor at the time of initiation of low-dose corticosteroid therapy (P < 0.0001), need for mechanical ventilation (P = 0.0001) and renal replacement therapy (P < 0.0001), while the impaired adrenal reserve did not affect 28-day mortality (81% versus 82%; P = 0.8679). After adjusting for potential confounding factors, the time to initiation of low-dose corticosteroid therapy was still significantly associated with 28-day mortality (adjusted odds ratio (OR) 1.025, 95% confidence interval (CI) 1.007 to 1.044, P = 0.0075). The early therapy group (administered within 6 hours after the onset of septic shock, n = 66) had a 37% lower mortality rate than the late therapy group (administered more than 6 hours after the onset of septic shock, n = 112) (32% versus 51%, P = 0.0132).ConclusionsEarly initiation of low-dose corticosteroid therapy was significantly associated with decreased mortality.

Improvements in Compliance With Resuscitation Bundles and Achievement of End Points After an Educational Program on the Management of Severe Sepsis and Septic Shock

ABSTRACT The objectives of this study were to determine whether an educational program could improve compliance with resuscitation bundles and the outcomes of patients with severe sepsis or septic shock and to evaluate which resuscitation bundle end points were associated with in-hospital mortality. This was a retrospective observational study of 366 patients (163 of historical controls and 203 of treatment patients) with severe sepsis or septic shock who presented to the emergency department between May 2007 and July 2009. Compliance with resuscitation bundles and achievement of the corresponding end points were compared before and after the 3-month educational program. Compliance with central line insertion and monitoring of central venous pressure (29% vs. 67%, P < 0.001) and central venous oxygen saturation (ScvO2) (25% vs. 68%, P < 0.001) was significantly improved after the educational program. The achievement of target ScvO2 within the first 6 h was significantly improved (62% vs. 88%, P < 0.001). In-hospital mortality was independently associated with adequate fluid challenge (odds ratio [OR], 0.161; 95% confidence interval [CI], 0.046–0.559) and the achievement of target mean arterial pressure (OR, 0.056; 95% CI, 0.008–0.384) and ScvO2 (OR, 0.251; 95% CI, 0.072–0.875) among the five sepsis resuscitation bundles. In conclusion, an educational program can improve compliance with resuscitation bundles and achievement of their corresponding end points.

The adverse effect of emergency department crowding on compliance with the resuscitation bundle in the management of severe sepsis and septic shock

IntroductionThe aim of this study is to evaluate the effects of emergency department (ED) crowding on the implementation of tasks in the early resuscitation bundle during acute care of patients with severe sepsis and septic shock, as recommended by the Surviving Sepsis Campaign guidelines.MethodsWe analyzed the sepsis registry from August 2008 to March 2012 for patients presenting to an ED of a tertiary urban hospital and meeting the criteria for severe sepsis or septic shock. The ED occupancy rate, which was defined as the total number of patients in the ED divided by the total number of ED beds, was used for measuring the degree of ED crowding. It was categorized into three groups (low; intermediate; high crowding). The primary endpoint was the overall compliance with the entire resuscitation bundle.ResultsA total of 770 patients were enrolled. Of the eligible patients, 276 patients were assigned to the low crowding group, 250 patients to the intermediate crowding group, and 244 patients to the high crowding group (ED occupancy rate: ≤ 115; 116–149; ≥ 150%). There was significant difference in compliance rates among the three groups (31.9% in the low crowding group, 24.4% in the intermediate crowding group, and 16.4% in the high crowding group, P < 0.001). In a multivariate model, the high crowding group had a significant association with lower compliance (adjusted odds ratio (OR), 0.44; 95% confidence interval (CI), 0.26 to 0.76; P = 0.003). When the ED occupancy rate was included as a continuous variable in the model, it had also a negative correlation with the overall compliance (OR of 10% increase of the ED occupancy rate, 0.90; 95% CI, 0.84 to 0.96, P = 0.002).ConclusionsED crowding was significantly associated with lower compliance with the entire resuscitation bundle and decreased likelihood of the timely implementation of the bundle elements.

Factors influencing compliance with early resuscitation bundle in the management of severe sepsis and septic shock.

ABSTRACT The Surviving Sepsis Campaign guidelines recommend implementing a 6-h resuscitation bundle, which has been associated with reduced mortality of patients presenting with severe sepsis or septic shock. However, this resuscitation bundle has not yet become a widely implemented treatment protocol. It is still unclear what factors are associated with the rate of compliance with the resuscitation bundle. In this study, we evaluated the potential factors associated with implementation and compliance of a 6-h resuscitation bundle in patients presenting with severe sepsis or septic shock in the emergency department. We conducted a retrospective observational study involving adult patients presenting with severe sepsis or septic shock in the emergency department of a tertiary care hospital during the period between August 2008 and July 2010. The resuscitation bundle consisted of seven interventions according to the Surviving Sepsis Campaign guidelines. The primary outcome measure was the rate of high compliance with the 6-h resuscitation bundle, defined as implementation of more than five of seven interventions. Multivariable logistic regression analysis was used to adjust for the confounding factors. A total of 317 patients were enrolled into the study. One hundred seventy-two patients (54.3%) were assigned to the high compliance group, and 145 patients (45.7%) to the low compliance group. Significant factors associated with high compliance of the 6-h resuscitation bundle were hyperthermia (adjusted odds ratio [OR], 1.37; 95% confidence interval [95% CI], 1.10–1.70), care from experienced nurses who had 3 or more years of clinical experience (adjusted OR, 1.69; 95% CI, 1.10–2.58), and care from senior residents or board-certified emergency physicians (adjusted OR, 3.68; 95% CI, 1.68–6.89). Factors related with lower compliance were cryptic shock (adjusted OR, 0.26; 95% CI, 0.13–0.52) and higher serum lactate levels (adjusted OR, 0.90; 95% CI, 0.82–0.98). Furthermore, we found several potential factors that influence compliance with the sepsis resuscitation bundle. To improve the compliance with the resuscitation bundle, interventions focusing on those factors will be needed.

The body mass index as a prognostic factor of critical care.

Background/Aims Obesity is a worldwide concern, but its influence on critical care outcomes is not well understood. We tested the hypothesis that abnormal body mass index (BMI) would be an independent predictor of higher mortality rates in intensive care unit (ICU). Methods We retrospectively reviewed patients who had admitted to the ICU from January 2007 to December 2007. Admission BMI was analyzed as both a three categorical (underweight, < 18.5 kg/m2; normal weight, 18.5 to 24.9 kg/m2; overweight and obese, ≥ 25 kg/m2) and continuous variables among all patients with an ICU lenth of stay ≥ 4 days. The primary outcome was ICU mortality. Results The multivariate analysis on ICU mortality selected Mortality Prediction Model-Admission (MPM at time zero) (hazard ratio [HR], 1.024; p = 0.001; 95% confidence interval [CI], 1.010 to 1.037), failed extubation (HR, 5.092; p = 0.0001; 95% CI, 2.742 to 9.456) as significant risk factors. When controlling these variables, none of the BMI group and BMI as a continuous variable had an independent association with ICU mortality. Conclusions BMI did not have a significant influence on ICU mortality. The ICU mortality was influenced more strongly by severity of illness and failed extubation rather than BMI.

Prognostic Factors for Endotracheal Silicone Stenting in the Management of Inoperable Post-Intubation Tracheal Stenosis

Purpose Stenting has been developed to deal with airway stenosis and is applicable in patients with post-intubation tracheal stenosis (PITS) in whom surgery would not be indicated. The purpose of this study was to investigate the prognostic factors in inoperable patients in whom a silicone stent was inserted due to PITS. Materials and Methods We retrospectively evaluated 55 PITS patients undergoing silicone stenting between January 2001 and December 2009. Results Silicone stent was inserted to narrowed trachea after the combination of pre-dilatation including laser cauterization, mechanical bougienation and ballooning. Following airway stabilization, the stent could be removed successfully in 40% (22/55) of the patients after median 12 months of stenting. However, in 60% (33/55) of patients, the stent could not be removed successfully and surgical management was needed after initial stabilization. Multivariate analysis revealed that the stent could be successfully removed more frequently in those who do not have cardiovascular disease [odds ratio (OR)=12.195; p=0.036] and the intervention was performed within 6 months after intubation (OR=13.029; p=0.031). Conclusion Among those patients undergoing silicone stenting due to PITS, the stent could be successfully removed when patients do not have cardiovascular disease and stented within 6 months after intubation.

The Incidence, Causes, and Prognostic Significance of New- Onset Thrombocytopenia in Intensive Care Units: A Prospective Cohort Study in a Korean Hospital

This study was designed to investigate the incidence, causes, and outcomes of new-onset thrombocytopenia (NOT) in Korean intensive care units (ICUs). A prospective cohort study was conducted in medical ICUs of Samsung Medical Center between August 2010 and February 2011. All newly admitted patients were included if they stayed in the ICU for more than 48 hr and did not have thrombocytopenia upon admission. A total of 186 patients were included. NOT developed in 37.1%. Most common cause of NOT was sepsis with disseminated intravascular coagulation (66.7%), followed by drug-induced thrombocytopenia (18.8%), and heparin-induced thrombocytopenia (2.9%). IgG-specific antibody to platelet factor 4/heparin was positive in 2.4% among patients treated with heparin, and thrombosis occurred in two patients. Twenty eight-day mortality was higher in patients that developed NOT compared to those that did not develop NOT (39.1% vs 12%, P < 0.001). NOT increased the odds ratio of 28-day mortality and was an independent risk factor for mortality (OR 3.52; 95% CI 1.32-9.38; P = 0.012). In conclusion, NOT is common and is an independent risk factor for mortality in Korean ICU patients. Therefore, clinicians should make every effort to correct the causes of NOT.

Validation of the Simplified Acute Physiology Score 3 Scoring System in a Korean Intensive Care Unit

Purpose The Simplified Acute Physiology Score (SAPS) 3 was recently proposed to reflect contemporary changes in intensive care practices. SAPS 3 features customized equations for the prediction of mortality in different geographic regions. However, the usefulness of SAPS 3 and its customized equation (Australasia SAPS 3) have never been externally validated in Korea. This study was designed to validate SAPS 3 and Australasia SAPS 3 for mortality prediction in Korea. Materials and Methods A retrospective analysis of the prospective intensive care unit (ICU) registry was conducted in the medical ICU of Samsung Medical Center. Calibration and discrimination were determined by the Hosmer-Lemeshow test and area under the receiver operating characteristic (aROC) curve from 633 patients. Results The mortalities (%) predicted by SAPS 3, Australasia SAPS 3, and SAPS II were 42 ± 28, 39 ± 27 and 37 ± 31, respectively. The calibration of SAPS II was poor (p = 0.003). SAPS 3 and Australasia SAPS 3 were appropriate (p > 0.05). The discriminative power of all models yielded aROC values less than 0.8. Conclusion In Korea, mortality rates predicted using general SAPS 3 and Australasia SAPS 3 exhibited good calibration and modest discrimination. However, Australasia SAPS 3 did not improve the mortality prediction. To better predict mortality in Korean ICUs, a new equation may be needed specifically for Korea.

Outcomes in critically ill patients with hematologic malignancies who received renal replacement therapy for acute kidney injury in an intensive care unit

INTRODUCTION In critically ill patients with hematologic malignancies, acute kidney injury (AKI) usually occurs in the context of multiple organ failure due to various etiologies and is associated with poor prognosis. The objective of the present study was to identify the prognostic factors associated with intensive care unit (ICU) mortality in patients with hematologic malignancies and AKI requiring renal replacement therapy (RRT). METHODS We retrospectively evaluated 94 patients with hematologic malignancies and AKI who received RRT in the ICU of Samsung Medical Center, Seoul, Korea, between January 2004 and December 2007. RESULTS The study sample included 65 men and 29 women with a median age of 49 years (interquartile range [IQR], 36-61 years). The median Simplified Acute Physiology Score II and Sequential Organ Failure Assessment (SOFA) scores at ICU admission were 64 (IQR, 46-79) and 13 (IQR, 9-16), respectively. The RRT for AKI was initiated at a median time of 1 day (IQR, 0-4 day) after ICU admission. Seventy-two (77%) patients died in the ICU after a median time of 4 days (IQR, 2-20 days) after the initiation of RRT. Among the 22 patients who survived, 5 (23%) required RRT after ICU discharge. Intensive care unit mortality was associated with an etiology of AKI, Simplified Acute Physiology Score II score, and SOFA score. Modified SOFA (mSOFA) score (defined as the sum of the 5 nonrenal components of the SOFA score) at the initiation of RRT was lower in survivors than in nonsurvivors. In a multiple logistic regression analysis, ICU mortality was independently associated with mSOFA score (odds ratio, 1.83 per mSOFA score increase; 95% confidence interval, 1.38-2.42) at the initiation of RRT. The estimated area under the curve for mSOFA score was 0.902 (95% confidence interval, 0.831-0.972). CONCLUSION The severity of organ failure, excluding renal failure, at initiation of RRT was independently associated with ICU mortality in patients with hematologic malignancies and AKI requiring RRT.

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.