Prognostication in Very Old Intensive Care Patients with Acute Kidney Injury.

BACKGROUND: Acute kidney injury (AKI) is a risk factor for morbidity and mortality during critical illness especially in very old patients admitted to intensive care units. OBJECTIVES: To identify prognostic markers for AKI patients. METHODS: This single-center retrospective study was based on a patient registry of a medical intensive care unit. Hospital records of patients aged 80 years or older admitted between 2005 and 2015 were examined. Patients who developed AKI according to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines within 4 days of admission were included in this study. RESULTS: The study comprised 96 patients with AKI and 81 age- and sex-matched controls without AKI. Mean acute physiology and chronic health evaluation (APACHE) II score was 30 with an ICU mortality of 27% in very old patients with AKI. The odds ratio of hospital mortality for these patients was 5.02 compared to controls (49% vs. 16%). APACHE II score and fluid balance in the first 2 days of ICU admission were the strongest predictors of ICU mortality with an area under the receiver operating characteristic of 0.76. Of the 47 patients with AKI who survived hospital admission, 30 were discharged home. CONCLUSIONS: Mortality was increased in very old ICU patients with AKI. Among survivors, two-thirds returned home.

Successful Treatment of Near Fatal Cardiogenic Shock Following Toxic Mushroom Ingestion.

Myocardial injury and hemodynamic compromise following toxic mushroom ingestion is rare. Here we present a case of cardiogenic shock after Amanita proxima ingestion, presenting with severe hemodynamic collapse necessitating mechanical circulatory support. Prompt identification, multidisciplinary clinical decision making, and timely treatment resulted in an outstanding complete clinical resolution. (Level of Difficulty: Intermediate.).

Comparison of Patients Undergoing Tracheostomy in the Intensive Care Unit versus in the Wards.

BACKGROUND: In Israel, critically ill patients are ventilated and managed in intensive care units or general wards. OBJECTIVES: To compare the mortality rates and long-term cognitive and functional outcomes of ventilated patients who underwent tracheostomy insertion in the Medical ICU (MICU) versus those cared for in the in-patient wards. METHODS: The study comprised 170 patients who underwent percutaneous dilatational tracheostomy (PDT) over an 18-month period in the MICU (n=102) and in in-patient wards (internal medicine and neurology) (n=68). Telephone interviews were conducted with living patients and/or their relatives at least 6 months after discharge from the hospital. RESULTS: Ward patients were 10 years older than ICU patients undergoing PDT (P = 0.003). The length of stay (LOS) in the wards was longer than in the ICU (P < 0.001), whereas the total LOS in the hospital was similar (P = 0.43). ICU mortality was lower than in the wards (P = 0.001) but hospital mortality was comparable between the two groups (P = 0.17). At 6 months follow-up more ICU patients were fully conscious, weaned from ventilation, and decannulated. More patients in the ICU group were at home and were independent or had mildly impaired activities of daily living. More patients in the ward group were residing in long-term care facilities with functional limitations. CONCLUSIONS: MICU patients who undergo tracheostomy may have a good long-term functional and cognitive outcome. More studies are needed to further assess long-term outcomes in these patients.

Description of 3 patients with myasthenia gravis and COVID-19.

BACKGROUND: The COVID-19 pandemic presents two main concerns for patients with myasthenia gravis (MG); chronic immunosuppression may put them at greater risk, and some proposed treatments for COVID-19 could cause MG exacerbation. CASE DESCRIPTION: We present three patients with generalized seropositive MG who developed COVID-19. All patients had a favorable outcome, with only one patient experiencing exacerbation. In this case, exacerbation began before COVID-19; she required ICU admission, non-invasive ventilatory support, and received hydroxychloroquine, lopinavir and ritonavir which were well tolerated. One patient received IVIG in place of scheduled plasma exchange. CONCLUSION: Outcome was favorable in all cases despite immunosuppressive therapy, use of experimental COVID-19 medication and switching of plasma exchange for IVIG.

Implementation of a structured communication tool improves family satisfaction and expectations in the intensive care unit.

BACKGROUND: Intensive care unit (ICU) physicians should provide relatives of critically ill patients with appropriate and clear information, regarding prognosis, treatment options and expectations. OBJECTIVES: To assess whether a structured communication tool improves satisfaction with care and engenders realistic expectations among relatives of critically ill patients. STUDY DESIGN: A controlled, pre-post intervention design was implemented in the General and Medical ICUs in the Hadassah-Hebrew University Medical Center, Jerusalem, Israel. METHODS: Forty relatives of patients who received usual communication from the medical staff (control group) were interviewed. We then implemented a structured communication tool and another forty family members were interviewed (intervention group). The ICU physicians who participated in the family meeting were also interviewed. RESULTS: Satisfaction in the intervention group was higher regarding ease of obtaining the information (90% vs 70%, p = .025) and the consistency of information provided (92.5% vs 77.5%, p = .057). There was better correlation between physicians' and relatives' expectations in the intervention group regarding hospital survival (Kappa 0.322 vs 0.054, p = .01). Physicians predicted more accurately patients' actual hospital survival. CONCLUSIONS: A structured communication tool was associated with improved family satisfaction with communication and expectations regarding hospital survival. Further research is required to evaluate this promising intervention.

Approaches to patients and families with strong religious beliefs regarding end-of-life care.

PURPOSE OF REVIEW: End-of-life (EOL) decisions with limitations are made daily in ICUs around the world and may involve between 2 and 22% of patients admitted to an ICU. EOL decisions may be affected by numerous factors, including location and religion. This review aims to determine an approach to patients and families with strong religious views. RECENT FINDINGS: Different religions have different approaches and beliefs regarding EOL care. Religious people choose more active life-sustaining measures than would nonreligious people. The patient's views on EOL care should be understood, although this is often not possible and the family members' or surrogates' understanding of the patient's wishes is relied upon. This is problematic as the family's wishes may differ from those of the patient. Family members may also have different religious beliefs or have different expressions of their beliefs. Through an open communication with the patient and/or family members, an understanding of the patient's views can be obtained and decisions regarding their involvement in decision making can be taken. Conflicts can be resolved by an interdisciplinary team approach including religious leaders. SUMMARY: Through proper open communication and understanding of the patient's and/or family's views on EOL care and involvement of religious leaders, decisions can be made regarding how to further care for the patient.

End-of-Life Practices in the Intensive Care Unit: The Importance of Geography, Religion, Religious Affiliation, and Culture.

End-of-life decisions are made daily in intensive care units worldwide. There are numerous factors affecting these decisions, including geographical location as well as religion and attitudes of caregivers, patients, and families. There is a spectrum of end-of-life care options from full continued care, withholding treatment, withdrawing treatment, and active life-ending procedures.