Vrinda Trivedi

Impact of obesity on sepsis mortality: A systematic review.

PURPOSE Sepsis and severe sepsis are the most common cause of death among critically ill patients admitted in medical intensive care units. As more than one-third of the adult population of the United States is obese; we undertook a systematic review of the association between obesity and mortality among patients admitted with sepsis, severe sepsis, or septic shock. MATERIALS AND METHODS A systematic review was conducted to identify pertinent studies using a comprehensive search strategy. Studies reporting mortality in obese patients admitted with sepsis were identified. RESULTS Our initial search identified 183 studies of which 7 studies met our inclusion criteria. Three studies reported no significant association between obesity and mortality, 1 study observed increased mortality among obese patients, whereas 3 studies found lower mortality among obese patients. CONCLUSION Our review of the current clinical evidence of association of obesity with sepsis mortality revealed mixed results. Clinicians are faced with a number of challenges while managing obese patients with sepsis and should be mindful of the impact of obesity on antibiotics administration, fluid resuscitation, and ventilator management. Further studies are needed to elicit the impact of obesity on mortality in patients with sepsis.

Short and long-term mortality in women and men undergoing primary angioplasty: A comprehensive meta-analysis ☆ ☆☆

INTRODUCTION Women with acute myocardial infarction are treated less aggressively than men and have a higher mortality. It is possible that these sex-related differences in outcome are a result of differences in baseline risk and management. METHODS AND RESULTS We undertook a meta-analysis to study the differences in mortality among women and men with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (P-PCI). Studies reporting sex-specific crude mortality rates and/or adjusted effect estimates in STEMI patients undergoing P-PCI were identified. Among 48 studies, involving 103,895 patients, (26,556 women and 77,337 men), the crude in-hospital [pooled relative risk (RR): 1.94, 95% confidence interval (CI): 1.74-2.16, p<0.001; 23 studies (n=43,872)], 30-day [RR: 1.76, 95% CI: 1.50-2.07, p<0.001; 20 studies (n=43,279)], and long-term [RR: 1.60, 95% CI: 1.46-1.76, p<0.001; 26 studies (n=51,656)] mortality was significantly higher in women compared to men. When meta-analysis using adjusted effect estimates from individual studies was performed, in-hospital [RR: 1.31, 95% CI: 1.08-1.65, p=0.007; 14 studies (n=33,380)] and 30-day mortality [RR: 1.19, 95% CI: 1.01-1.39, p=0.03; 14 studies (n=28,564)] remained significant while long-term mortality [RR: 1.01, 95% CI: 0.93-1.11, p=0.75; 20 studies (n=52,492)] was no longer different between women and men. CONCLUSIONS Sex-based differences exist in short and long-term mortality among patients with STEMI undergoing P-PCI. However, these differences were markedly attenuated following adjustment for clinical differences and/or hospital course. Despite adjustment, short-term mortality remains higher in women than men, while long-term mortality was no longer significantly different.

Duration of Dual Antiplatelet Therapy in Patients with an Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

BACKGROUND The recent American Heart Association/American College of Cardiology guidelines on duration of dual antiplatelet therapy (DAPT) recommend DAPT for 1 year in patients presenting with an acute coronary syndrome, with a Class IIb recommendation for continuation. We aim to assess the evidence for these recommendations using a meta-analytic approach. METHODS We searched electronic databases for randomized trials comparing short-term (≤6 months) vs 12-month vs extended (>12 months) DAPT in patients with an acute coronary syndrome undergoing percutaneous coronary intervention. We evaluated all-cause mortality, cardiovascular mortality, myocardial infarction, stent thrombosis, and major bleeding. A random-effects model was used to calculate pooled relative risk (RR) and 95% confidence intervals (CI). RESULTS We included 8 trials comprising 12,917 patients with an acute coronary syndrome; 5 trials compared short-term vs 12-month/extended DAPT, whereas 3 trials compared 12-month vs extended DAPT. There was no significant difference in cardiovascular mortality (RR 1.04; 95% CI, 0.67-1.60), myocardial infarction (RR 1.08; 95% CI, 0.79-1.47), or major bleeding (RR 0.91; 95% CI, 0.49-1.69) between short-term and 12-month/extended DAPT. However, compared with extended DAPT, 12-month DAPT showed significantly higher risk of myocardial infarction (RR 2.00; 95% CI, 1.47-2.73), but reduced risk of major bleeding (RR 0.58; 95% CI, 0.34-0.98). All-cause mortality was found to be similar between 12-month and extended DAPT. CONCLUSIONS In acute coronary syndrome, short-term DAPT may be reasonable for some patients, whereas extended DAPT may be appropriate in select others. An individualized approach is needed, taking into account the competing risks of bleeding and ischemic events.

Impact of Obesity on Outcomes in a Multiethnic Cohort of Medical Intensive Care Unit Patients

Purpose: To examine the association of obesity with in-hospital mortality and complications during critical illness. Methods: We performed a retrospective analysis of a multiethnic cohort of 699 patients admitted to medical intensive care unit between January 2010 and May 2011 at Mount Sinai St. Luke’s and Mount Sinai West Hospitals, tertiary care centers in New York City. Multivariate logistic regression analysis was used to evaluate the association between obesity (body mass index [BMI] ≥ 30] and in-hospital mortality. Subgroup analysis was performed in elderly patients (age ≥65 years). Results: Compared to normal BMI, obese patients had lower in-hospital mortality (24.4% vs 17.6%, P = .04). On multivariate analysis, obesity was independently associated with lower in-hospital mortality (odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.27-0.89, P = .018). There was no significant difference in rates of mechanical ventilation, reintubation, and vasopressor requirement across BMI categories. In subgroup analysis, elderly obese patients did not display lower in-hospital mortality (adjusted OR: 0.85, 95% CI: 0.40-1.82, P = .68). Conclusion: Our study supports the hypothesis that obesity is associated with decreased mortality during critical illness. However, this finding was not observed among elderly obese patients. Further studies should explore the interaction between age, obesity, and outcomes in critical illness.

Ventilation in acute respiratory distress syndrome: importance of low-tidal volume

Acute respiratory distress syndrome (ARDS) is a lifethreatening syndrome that affects more than 150,000 patients annually in the United States with nearly 40–60% mortality (1-3). Over the past two decades, significant progress has been made in the fields of critical care, mechanical ventilation, fluid management and sedation practices that have impacted the practice of intensive care medicine, including the management of ARDS (3-5).

Utility of the Richmond Agitation-Sedation Scale in evaluation of acute neurologic dysfunction in the intensive care unit.

Multiorgan failure is common in the intensive care unit (ICU) setting with increasing mortality with greater number of dysfunctional organs. An objective assessment of the severity of individual organ dysfunction is essential for clinical care and research. Severity of illness scoring systems in the ICU have been developed over the past 30 years and are currently used widely to risk stratify patients, predict hospital mortality, perform outcome based research, assess resource utilization and measure performance improvement in patient care (1,2). The Sequential Organ Failure Assessment (SOFA) was initially devised in 1994 by an expert panel to describe severity of organ dysfunction in patients with sepsis, and has subsequently been validated as a useful marker for predicting outcomes in medical and surgical ICUs (1). Each of the six organ systems (respiratory, cardiovascular, renal, hepatic, neurologic, coagulation) are assigned values between 0 (normal function) and 4 (significant dysfunction), total scores can range from 0 to 24 (1). In the recent Third International Consensus Definition for Sepsis and Septic shock (Sepsis-3), organ dysfunction due to infection is identified as an acute change in the total SOFA score by ≥2 points. The task force has also developed quick SOFA (qSOFA) model consisting of clinical criteria (systolic blood pressure of 100 mmHg or less, respiratory rate of 22/min or greater, altered mental status) for rapid bedside identification of patients at risk of worse outcomes (3). Serial SOFA score assessments in the first 48 hours after ICU admission correlate well with mortality (4). When compared to other organ dysfunction scores, SOFA has been shown to be consistent and an accurate predictor of mortality (1). Neurologic component of the SOFA score is derived from the Glasgow Coma Scale (GCS). GCS was first developed in 1974 by Teasdale and Jennett as a tool to objectively assess consciousness in patients with head injuries and offer a standardized approach that providers could utilize to monitor neurologic exam (5). Verbal, motor and eye response in the GCS define level of consciousness. Currently, the GCS is used in a broad spectrum of medical and surgical ICU patients and is an integral part of severity of illness and prognostic scoring systems such as the Acute Physiology and Chronic Health Evaluation (APACHE), Simplified Acute Physiology Score (SAPS), SOFA, Multiple Organ Dysfunction Score (MODS) and Logistic Organ Dysfunction Score (LODS) (1). However, several limitations of using the GCS in the critically ill population have been identified; including low interobserver reliability, inability to assess verbal component in tracheally intubated patients, weak prognostic value and erroneous estimation by providers due to lack of standardized assessments (6,7). The Richmond Agitation-Sedation Scale (RASS) is used for routine neurological assessments in the ICU, especially in patients without traumatic brain injury. RASS is a 10 point scale with discrete criteria, with four levels of agitation (+1 to +4), one level for calm and alert state (0), and 5 levels of sedation (−1 to −5) (8). It was initially devised to assist with administration and titration of sedation and analgesia in the ICU and has been shown to have high interobserver reliability, and consistency in estimating the patient’s level of consciousness. It is easy to recall and can be administered in less than a minute with a simple three step sequence (observation, response to verbal stimulation and response to physical stimulation) (8-10). Sedation assessments based on the RASS are recommended by critical care consensus guidelines (10).

247: USE OF ECMO WITH AND WITHOUT INTRA-AORTIC BALLOON PUMP SUPPORT IN CARDIOGENIC SHOCK: A META-ANALYSIS.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) transduction signaling involves Opn4 and Opn3 receptor. G protein-coupled receptor kinase (GRK)2 both amplifies and prevents desensitization of the photorelaxation response following repeated stimulation. Photorelaxation in PAs occurs by NO-independent mechanism. Photorelaxation signal transduction involves sGC, but not Protein Kinase G. Photorelaxation signal transduction involves PDE6, and vessel hyperpolarization. In vivo study with isolated, perfused lung model demonstrates photorelaxation to hypoxia-induced pulmonary vasoconstriction. Conclusions: Photorelaxation response in the pulmonary vasculature happens through a signaling cascade involving Opn3, Opn4, GRK2, sGC/cGMP, and PDE6. Combination therapy, including therapeutic targets to control GRK2 activity and light intensity, may play a key role in adjusting vasoreactivity to photo-stimulation and that a therapeutic approach using light stimulation or targeting Opn3, Opn4, GRK2, and/or PDE6 may provide another option for treatment of PH.