Dynamic Prediction of Mortality Using Longitudinally Measured Pediatric Sequential Organ Failure Assessment Scores: A Joint Modeling Approach.

OBJECTIVES: The pediatric Sequential Organ Failure Assessment (pSOFA) score was designed to track illness severity and predict mortality in critically ill children. Most commonly, pSOFA at a point in time is used to assess a static patient condition. However, this approach has a significant drawback because it fails to consider any changes in a patients' condition during their PICU stay and, especially, their response to initial critical care treatment. We aimed to evaluate the performance of longitudinal pSOFA scores for predicting mortality. DESIGN: Single-center, retrospective cohort study. SETTING: Quaternary 40-bed PICU. PATIENTS: All patients admitted to the PICU between 2015 and 2021 with at least 24 hours of ICU stay. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We calculated daily pSOFA scores up to 30 days, or until death or discharge from the PICU, if earlier. We used the joint longitudinal and time-to-event data model for the dynamic prediction of 30-day in-hospital mortality. The dataset, which included 9146 patients with a 30-day in-hospital mortality of 2.6%, was divided randomly into training (75%) and validation (25%) subsets, and subjected to 40 repeated stratified cross-validations. We used dynamic area under the curve (AUC) to evaluate the discriminative performance of the model. Compared with the admission-day pSOFA score, AUC for predicting mortality between days 5 and 30 was improved on average by 6.4% (95% CI, 6.3-6.6%) using longitudinal pSOFA scores from the first 3 days and 9.2% (95% CI, 9.0-9.5%) using scores from the first 5 days. CONCLUSIONS: Compared with admission-day pSOFA score, longitudinal pSOFA scores improved the accuracy of mortality prediction in PICU patients at a single center. The pSOFA score has the potential to be used dynamically for the evaluation of patient conditions.

Interfacility transfer of the critically ill: Transfer status does not influence survival.

PURPOSE: To estimate differences in case-mix adjusted hospital mortality between adult ICU patients who are transferred during their ICU-stay and those who are not. METHODS: 19,260 visits to 12 ICUs in Nova Scotia (NS), Canada April 2018-September 2023 were analyzed. Data were obtained from the NS Provincial ICU database. Generalized additive models (GAMs) were used to estimate differences in case-mix adjusted hospital mortality between patients who underwent transfer and those who did not. RESULTS: 1040/19,260 (5%) ICU visits involved interfacility-transfer. No difference in hospital mortality was identified between transferred and non-transferred patients by GAM (OR, 0.99, 95% CI, 0.82 to 1.19; p = 0.91). No mortality difference was observed between patients undergoing a single transfer versus multiple (OR, 0.87; 95% CI, 0.45 to -1.69; p = 0.68). A GAM including the categories no transfer, one transfer, and multiple transfers identified a difference in hospital mortality for patients that underwent multiple transfers compared to non-transferred patients (OR, 0.68; 95% CI, 0.46 to 1.00, p = 0.05), but no difference was identified in a post-hoc matched cohort sensitivity analysis (OR, 0.68; 95% CI, 0.46 to 1.01, p = 0.05). CONCLUSION: The transfer of critically ill patients between ICUs in Nova Scotia did not impact case-mix adjusted hospital mortality.

Individualized prediction of critical illness in older adults: Validation of an elders risk assessment model.

BACKGROUND: The electronic health record (EHR) presents new opportunities for the timely identification of patients at high risk of critical illness and the implementation of preventive strategies. This study aims to externally validate an EHR-based Elders Risk Assessment (ERA) score to identify older patients at high risk of future critical illness during a primary care visit. METHODS: This historical cohort study included patients aged ≥65 years who had primary care visits at Mayo Clinic Rochester, MN, between July 2019 and December 2021. The ERA score at the time of the primary care visit was used to predict critical illness, defined as death or ICU admission within 1 year of the visit. RESULTS: A total of 12,885 patients were included in the analysis. The median age at the time of the primary care visit was 75 years, with 44.6% being male. 93.7% of participants were White, and 64.2% were married. The median (25th, 75th percentile) ERA score was 4 (0, 9). 11.3% of study participants were admitted to the ICU or died within 1 year of the visit. The ERA score predicted critical illness within 1 year of a primary care visit with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.83-0.85), which indicates good discrimination. An ERA score of 9 was identified as optimal for implementing and testing potential preventive strategies, with the odds ratio of having the primary outcome in patients with ERA score ≥9 being 11.33 (95%CI 9.98-12.87). CONCLUSIONS: This simple EHR-based risk assessment model can predict critical illness within 1 year of primary care visits in older patients. The findings of this study can serve as a basis for testing and implementation of preventive strategies to promote the well-being of older adults at risk of critical illness and its consequences.

Price for waiting: the adverse outcomes of boarding critically ill elderly medical patients in the emergency department.

PURPOSE: Boarding, the period in which a patient spends in the emergency department (ED) before admission, may be hazardous to critically ill patients, particularly the elderly. This study investigated the associations of boarding with hospital course, prognosis, and medical expenditure in older patients. METHODS: From January 2019 to December 2021, the medical records of older patients (age ≥ 65) visiting the ED of a tertiary referral hospital who were admitted to the medical intensive care unit (ICU) were retrospectively reviewed. Eligible patients were categorized into two groups according to boarding time with a cutoff set at 6 h. Primary outcomes were in-hospital mortality, ICU/hospital length of stay, and total/average hospitalization cost. Subgroup analyses considered age and disease type. RESULTS: Among 1318 ICU admissions from the ED, 36% were subjected to boarding for over 6 h. Prolonged boarding had a longer ICU (8.9 ± 8.8 vs. 11.2 ± 12.2 days, P < .001) and hospital (17.8 ± 20.1 vs. 22.8 ± 23.0 days, P < .001) stay, higher treatment cost (10.4 ± 13.9 vs. 13.2 ± 16.5 thousands of USD, P = .001), and hospital mortality (19% vs. 25% P = .020). Multivariate regression analysis showed a longer ICU stay in patients aged 65-79 (8.3 ± 8.4 vs. 11.8 ± 14.2 days, P < .001) and cardiology patients (6.9 ± 8.4 vs. 8.8 ± 9.7 days, P = .001). Besides, the treatment cost was also higher for both groups (10.4 ± 14.6 vs. 13.7 ± 17.7 thousands of USD, P = .004 and 8.4 ± 14.0 vs. 11.7 ± 16.6 thousands of USD, P < .001, respectively). CONCLUSION: Extended ED boarding for critically ill medical patients over 65 years old was associated with negative outcomes, including longer ICU/hospital stays, higher treatment costs, and hospital mortality.

Assessment of Nutritional Risk Scores (the Nutritional Risk Screening 2002 and Modified Nutrition Risk in Critically Ill Scores) as Predictors of Mortality in Critically Ill Patients on Extracorporeal Membrane Oxygenation.

Nutritional risk is associated with intensive care unit (ICU) stay and mortality, the Nutritional Risk Screening 2002 (NRS 2002) and the modified Nutritional Risk in the Critically Ill (mNUTRIC) score are assessment instruments and useful in predicting the risk regarding mortality in ICU patients. Our aim was to assess the effects of mNUTRIC and NRS 2002 on mortality in patients on extracorporeal membrane oxygenation (ECMO). A retrospective cohort study was performed and 78 patients were included for final analysis. In the current study, the NRS 2002 and the mNUTRIC score within 24 hours before starting ECMO were applied to assess patients' nutritional status on ECMO and explore the relationship between nutritional status and patient outcomes. This study suggests that both mNUTRIC and NRS 2002 scores were found to be significant independent risk and prognostic factors for in-hospital and 90 day morality among ECMO patients based on multivariable logistic regression analysis ( p < 0.05), with those in the high-risk group having higher in-hospital and 90 day mortality rates than those identified as being at low risk ( p < 0.001). In comparison to the NRS 2002 score, the mNUTRIC score demonstrated a superior prognostic ability in ECMO patients.

The safety and efficacy of high-speed train transport for critical children: a retrospective propensity score matching cohort study.

It is widely acknowledged that efficiency of pediatric critical care transport plays a vital role in treatment of critically-ill children. In developing countries, most critically-ill children were transported by ambulance, and a few by air, such as a helicopter or fixed airplane. High-speed train (HST) transport may be a potential choice for critically-ill children to a tertiary medical center for further therapy. This is a single-center, retrospective cohort study from June 01, 2016 to June 30, 2019. All the patients transported to the Pediatric Intensive Care Unit (PICU) of PLA general hospital were divided into two groups, HST group and ambulance group. The propensity score matching method was performed for the comparison between the two groups. Finally, a 2:1 patient matching was performed using the nearest-neighbor matching method without replacement. The primary outcome was hospital mortality. Secondary outcomes included duration of transport, transport cost, hospital stay, and hospitalization cost. A total of 509 critically-ill children were transported and admitted. Of them, 40 patients were transported by HST, and 469 by ambulance. The hospital mortality showed no difference between the two groups (p > 0.05). The transport distance in the HST group was longer than that in the ambulance group (1894.5 ± 907.09 vs. 902.66 ± 735.74, p < 0.001). However, compared to the HST group, the duration of transport time by ambulance was significantly longer (p < 0.001). No difference in vital signs, blood gas analysis, and critical illness score between groups at admission was noted (p > 0.05). There was no death during the transport. There was no difference between groups regarding the transport cost, hospital stays, and hospitalization cost (p > 0.05). High-quality tertiary medical centers are usually located in megacities. HST transport network for critically-ill children could be established to cover most regions of the country. Without increasing financial burden, HST medical transport can be a potentially promising option to improve the outcomes of critically-ill children in developing countries with developed HST network.Clinical Trial Registration: This study was registered at http://www.chictr.org.cn/index.aspx (chiCTR.gov; Identifier: ChiCTR2000032306).

Assessment of Sarcopenia in the Intensive Care Unit and 1-Year Mortality in Survivors of Critical Illness.

Skeletal muscle wasting in the intensive care unit (ICU) has been associated with mortality, but it is unclear whether sarcopenia, defined by skeletal muscle mass and function, is useful for detailed risk stratification after ICU discharge. In this cohort study, 72 critically ill patients with an ICU stay of ≥48 h were identified. Skeletal muscle mass was assessed from the muscle thickness (MT) of the patients' quadriceps using ultrasound images before ICU discharge. Skeletal muscle function was assessed from the patients' muscle strength (MS) before ICU discharge according to the Medical Research Council sum score. A diagnosis of sarcopenia in the ICU was made in patients with low MT and low MS. The study endpoint was 1-year mortality. Sarcopenia in the ICU was diagnosed in 26/72 patients (36%). After adjusting for covariates in the Cox regression, sarcopenia in the ICU was significantly associated with 1-year mortality (hazard ratio 3.82; 95% confidence interval, 1.40-10.42). Sarcopenia in the ICU, defined by low skeletal muscle mass and function, was associated with 1-year mortality in survivors of critical illness. Skeletal muscle mass and function assessed at the bedside could be used to identify higher-risk patients in the ICU.

Racial, ethnic, and socioeconomic disparities in paediatric critical care in the USA.

In an era of tremendous medical advancements, it is important to characterise and address inequities in the provision of health care and in outcomes. There is a large body of evidence describing such disparities by race or ethnicity and socioeconomic position in critically ill adults; however, this important issue has received less attention in children and adolescents (aged ≤21 years). This Review presents a summary of the available evidence on disparities in outcomes in paediatric critical illness in the USA as a result of racism and socioeconomic privilege. The majority of evidence of racial and socioeconomic disparities in paediatric critical care originates from the USA and is retrospective, with only one prospective intervention-based study. Although there is mixed evidence of disparities by race or ethnicity and socioeconomic position in general paediatric intensive care unit admissions and outcomes in the USA, there are striking trends within some disease processes. Notably, there is evidence of disparities in management and outcomes for out-of-hospital cardiac arrest, asthma, severe trauma, sepsis, and oncology, and in families' perceptions of care. Furthermore, there is clear evidence that critical care research is limited by under-enrolment of participants from minority race or ethnicity groups. We advocate for rigorous research standards and increases in the recruitment and enrolment of a diverse range of participants in paediatric critical care research to better understand the disparities observed, including the effects of racism and poverty. A clearer understanding of when, where, and how such disparities affect patients will better enable the development of effective strategies to inform practice, interventions, and policy.

Multimorbidity and Its Relationship With Long-Term Outcomes After Critical Care Discharge: A Prospective Cohort Study.

BACKGROUND: Survivors of critical illness have poor long-term outcomes with subsequent increases in health care utilization. Less is known about the interplay between multimorbidity and long-term outcomes. RESEARCH QUESTION: How do baseline patient demographics impact mortality and health care utilization in the year after discharge from critical care? STUDY DESIGN AND METHODS: Using data from a prospectively collected cohort, we used propensity score matching to assess differences in outcomes between patients with a critical care encounter and patients admitted to the hospital without critical care. Long-term mortality was examined via nationally linked data as was hospital resource use in the year after hospital discharge. The cause of death was also examined. RESULTS: This analysis included 3,112 participants. There was no difference in long-term mortality between the critical care and hospital cohorts (adjusted hazard ratio, 1.09; 95% CI, 0.90-1.32; P = .39). Prehospitalization emotional health issues (eg, clinical diagnosis of depression) were associated with increased long-term mortality (hazard ratio, 1.49; 95% CI, 1.14-1.96; P < .004). Health care utilization was different between the two cohorts in the year after discharge with the critical care cohort experiencing a 29% increased risk of hospital readmission (OR, 1.29; 95% CI, 1.11-1.50; P = .001). INTERPRETATION: This national cohort study has demonstrated increased resource use for critical care survivors in the year after discharge but fails to replicate past findings of increased longer-term mortality. Multimorbidity, lifestyle factors, and socioeconomic status appear to influence long-term outcomes and should be the focus of future research.

Evaluation of the incidence, characteristics, and outcomes of pediatric chronic critical illness.

Our aim was to determine characteristics of children with chronic critical illness (CCI) admitted to the pediatric intensive care unit (PICU) of a tertiary care children's hospital in Turkey. The current study was a multicenter retrospective cohort study that was done from 2014 to 2017. It involved three university hospitals PICUs in which multiple criteria were set to identify pediatric CCIs. Pediatric patients staying in the ICU for at least 14 days and having at least one additional criterion, including prolonged mechanical ventilation, tracheostomy, sepsis, severe wound (burn) or trauma, encephalopathy, traumatic brain injury, status epilepticus, being postoperative, and neuromuscular disease, was accepted as CCI. In order to identify the newborn as a chronic critical patient, a stay in the intensive care unit for at least 30 days in addition to prematurity was required. Eight hundred eighty seven (11.14%) of the patients who were admitted to the PICU met the definition of CCI and 775 of them (87.3%) were discharged to their home. Of CCI patients, 289 (32.6%) were premature and 678 (76.4%) had prolonged mechanical ventilation. The total cost values for 2017 were statistically higher than the other years. As the length of ICU stay increased, the costs also increased. Interestingly, high incidence rates were observed for PCCI in our hospitals and these patients occupied 38.01% of the intensive care bed capacity. In conclusion, we observed that prematurity and prolonged mechanical ventilation increase the length of ICU stay, which also increased the costs. More work is needed to better understand PCCI.

The Effect of Organ System Surgery on Intensive Care Unit Mortality in a Cohort of Critically Ill Surgical Patients.

BACKGROUND: The critical illness burden in the United States is growing with an aging population obtaining surgical intervention despite age-related comorbidities. The effect of organ system surgical intervention on intensive care units (ICUs) mortality is unknown. METHODS: We performed an 8-year retrospective analysis of surgical ICU patients. Poisson regression analysis was performed assessing the relative risk of in-hospital mortality based on surgical intervention. RESULTS: Of 468 000 ICU patients included, 97 968 (20.9%) were surgical admissions and 97 859 (99.9%) had complete outcomes data. Nonsurvivors were older (68.8 ± 15.4 vs. 62.7 ± 15.8 years, P < .001) with higher Acute Physiology, Age, Chronic Health Evaluation (APACHE) III Scores (81.4 ± 33.6 vs. 46.7 ± 20.1, P < .001. Patients with gastrointestinal (GI) (n = 1,558, 7.8%), musculoskeletal (n = 277, 5.5%), and neurological (n = 884, 4.6%) system operations had the highest mortality. Upon Poisson regression model, patients undergoing emergent operative interventions on the neurologic system (RR 1.86, 95% CI 1.67-2.07, P < .001) had increased relative risk of mortality when compared to emergent operative interventions on the cardiovascular system after controlling for pertinent covariates. Elective operative interventions on the respiratory (RR 2.39, 95% CI 2.03-2.80, P < .001), GI (RR 2.34, 95% CI 2.10-2.61, P < .001), and skin and soft tissue (RR 2.26, 95% CI 1.77-2.89, P < .001) systems had increased risk of mortality when compared to elective cardiovascular system surgery after controlling for pertinent covariates. CONCLUSION: We found significant differences in the risk of mortality based on organ system of operative intervention. The prognostication of critically ill patients undergoing surgical intervention is currently not accounted for in prognostic scoring systems.

Epidemiology of Chronic Critical Illness in Japan: A Nationwide Inpatient Database Study.

OBJECTIVES: The epidemiology of chronic critical illness is not well known. We aimed to estimate the prevalence, mortality, and costs associated with chronic critical illness in Japan. DESIGN: A nationwide inpatient administrative database study in Japan from April 2011 to March 2018. SETTING: Six hundred seventy-nine acute-care hospitals with ICU beds in Japan. PATIENTS: Adult patients who met our definition for chronic critical illness: one of six eligible clinical conditions (prolonged acute mechanical ventilation, tracheotomy, stroke, traumatic brain injury, sepsis, and severe wound) plus at least 8 consecutive days in an ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 2,395,016 ICU admissions during the study period, 216,434 (9.0%) met the definition for chronic critical illness. The most common eligible condition was prolonged acute mechanical ventilation (73.9%), followed by sepsis (50.6%), tracheostomy (23.8%), and stroke (22.8%). Overall inhospital mortality was 28.6%. The overall age-specific population prevalence was 42.0 per 100,000. The age-specific population prevalence steadily increased with age, reaching 109.6 per 100,000 in persons aged greater than 85 years. With extrapolation to national estimates in Japan, there were 47,729 chronic critical illness cases in 2011 and the number remained similar at 46,494 cases in 2017. Hospitalization costs increased gradually, rising from U.S.$2.3 billion in 2011 to U.S.$2.7 billion in 2017. Inhospital mortality decreased from 30.6% to 28.2%, whereas the proportion of patients with total/severe dependence increased from 29.6% to 33.2% and the proportion of patients with decreased consciousness at discharge increased from 18.7% to 19.6%. CONCLUSIONS: Using a nationwide inpatient database in Japan, we found substantial clinical and economic burdens of chronic critical illness in Japan. Chronic critical illness was particularly common in elderly people. Although inhospital mortality of chronic critical illness patients continues to decrease, costs and patients with dependence for activities of daily living or decreased consciousness at discharge are increasing.

Tracheotomy Timing and Outcomes in the Critically Ill: Complexity and Opportunities for Progress.

OBJECTIVES/HYPOTHESIS: To characterize the effects of tracheotomy timing at our institution on intensive care unit (ICU) length of stay (LOS) and overall hospital LOS. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective study was performed at a tertiary care medical center for patients undergoing tracheotomy over 2.5 years from January 1, 2016 through June 30, 2018. Demographics, survival, duration of endotracheal intubation, timing of tracheotomy, and ICU and overall hospital LOS were assessed. Tracheotomy was considered early (ET) if it was performed by day 7 of mechanical ventilation and late (LT) thereafter. Readmission, mortality, and costs were also tabulated for each aggregate group. Nonparametric statistics were used to compare results. RESULTS: Of the 536 patients included in the analysis, 160 received tracheotomy early and 376 late. Differences between age and sex were not statistically significant. Duration of total ICU stay was shortened by 65% (12.84 ± 17.69 days vs. 38.49 ± 26.61 days; P < .0001), and length of overall hospital course was reduced by 54% (22.71 ± 26.65 days vs. 50.37 ± 34.20 days; P < .0001) in the early tracheotomy group. Observed/expected (O/E) values standardized results to case mix index and revealed LOS of 1.5 for ET and 2.5 for LT, and mortality of 0.76 for ET and 1.25 for LT, and comparable readmissions of both groups. CONCLUSIONS: Early tracheotomy in ICU patients is associated with earlier ICU discharge, decreased length of overall hospital stay, and lower mortality when controlling for case mix index. Opportunities exist to optimize patient outcomes and O/E performance. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:282-287, 2021.

Observational Research for Therapies Titrated to Effect and Associated With Severity of Illness: Misleading Results From Commonly Used Statistical Methods.

OBJECTIVES: In critically ill patients, treatment dose or intensity is often related to severity of illness and mortality risk, whereas overtreatment or undertreatment (relative to the individual need) may further increase the odds of death. We aimed to investigate how these relationships affect the results of common statistical methods used in observational studies. DESIGN: Using Monte Carlo simulation, we generated data for 5,000 patients with a treatment dose related to the pretreatment mortality risk but with randomly distributed overtreatment or undertreatment. Significant overtreatment or undertreatment (relative to the optimal dose) further increased the mortality risk. A prognostic score that reflects the mortality risk and an outcome of death or survival was then generated. The study was analyzed: 1) using logistic regression to estimate the effect of treatment dose on outcome while controlling for prognostic score and 2) using propensity score matching and inverse probability weighting of the effect of high treatment dose on outcome. The data generation and analyses were repeated 1,500 times over sample sizes between 200 and 30,000 patients, with an increasing accuracy of the prognostic score and with different underlying assumptions. SETTING: Computer-simulated studies. MEASUREMENTS AND MAIN RESULTS: In the simulated 5,000-patient observational study, higher treatment dose was found to be associated with increased odds of death (p = 0.00001) while controlling for the prognostic score with logistic regression. Propensity-matched analysis led to similar results. Larger sample sizes led to equally biased estimates with narrower CIs. A perfect risk predictor negated the bias only under artificially perfect assumptions. CONCLUSIONS: When a treatment dose is associated with severity of illness and should be dosed "enough," logistic regression, propensity score matching, and inverse probability weighting to adjust for confounding by severity of illness lead to biased results. Larger sample sizes lead to more precisely wrong estimates.

Emergency and critical care services in Malawi: Findings from a nationwide survey of health facilities.

Background: Globally, critical illness causes up to 45 million deaths every year. The burden is highest in low-income countries such as Malawi. Critically ill patients require good quality, essential care in emergency departments and in hospital wards to avoid negative outcomes such as death. Little is known about the quality of care or the availability of necessary resources for emergency and critical care in Malawi. The aim of this study was to assess the availability of resources for emergency and critical care in Malawi using data from the Service Provision Assessment (SPA). Methods: We conducted a secondary data analysis of the SPA - a nationwide survey of all health facilities. We assessed the availability of resources for emergency and critical care using previously developed standards for hospitals in low-income countries. Each health facility received an availability score, calculated as the proportion of resources that were present. Resource availability was sub-divided into the seven a-priori defined categories of drugs, equipment, support services, emergency guidelines, infrastructure, training and routines. Results: Of the 254 indicators in the standards necessary for assessing the quality of emergency and critical care, SPA collected data for 102 (40.6%). Hospitals had a median resource availability score of 51.6% IQR (42.2-67.2) and smaller health facilities had a median of 37.5% (IQR 28.1-45.3). For the category of drugs, the hospitals' median score was 62.0% IQR (52.4-81.0), for equipment 51.9% IQR (40.7-66.7), support services 33.3% IQR (22.2-77.8) and emergency guidelines 33.3% IQR (0-66.7). SPA did not collect any data for resources in the categories of infrastructure, training or routines. Conclusion: Hospitals in Malawi lack resources for providing emergency and critical care. Increasing data about the availability of resources for emergency and critical care and improving the hospital systems for the care of critically ill patients in Malawi should be prioritized.

Critical Care Delivery Solutions in the Emergency Department: Evolving Models in Caring for ICU Boarders.

The National Academy of Medicine has identified emergency department (ED) crowding as a health care delivery problem. Because the ED is a portal of entry to the hospital, 25% of all ED encounters are related to critical illness. Crowding at both an ED and hospital level can thus lead to boarding of a number of critically ill patients in the ED. EDs are required to not only deliver immediate resuscitative and stabilizing care to critically ill patients on presentation but also provide longitudinal care while boarding for the ICU. Crowding and boarding are multifactorial and complex issues, for which different models for delivery of critical care in the ED have been described. Herein, we provide a narrative review of different models of delivery of critical care reported in the literature and highlight aspects for consideration for successful local implementation.

Morbidity and mortality in critically ill patients with invasive group A streptococcus infection: an observational study.

BACKGROUND: Group A streptococci (GAS) are known to cause serious invasive infections, but little is known about outcomes when patients with these infections are admitted to intensive care. We wanted to describe critically ill patients with severe sepsis or septic shock due to invasive GAS (iGAS) and compare them with other patients with severe sepsis or septic shock. METHODS: Adult patients admitted to a general intensive care unit (ICU) in Sweden (2007-2019) were screened for severe sepsis or septic shock according to Sepsis 2 definition. Individuals with iGAS infection were identified. The outcome variables were mortality, days alive and free of vasopressors and invasive mechanical ventilation, maximum acute kidney injury score for creatinine, use of continuous renal replacement therapy and maximum Sequential Organ Failure Assessment score during the ICU stay. Age, Simplified Acute Physiology Score (SAPS 3) and iGAS were used as independent, explanatory variables in regression analysis. Cox regression was used for survival analyses. RESULTS: iGAS was identified in 53 of 1021 (5.2%) patients. Patients with iGAS presented a lower median SAPS 3 score (62 [56-72]) vs 71 [61-81]), p <  0.001), had a higher frequency of cardiovascular cause of admission to the ICU (38 [72%] vs 145 [15%], p <  0.001) and had a higher median creatinine score (173 [100-311] vs 133 [86-208] µmol/L, p <  0.019). Of the GAS isolates, 50% were serotyped emm1/T1 and this group showed signs of more pronounced circulatory and renal failure than patients with non-emm1/T1 (p = 0.036 and p = 0.007, respectively). After correction for severity of illness (SAPS 3) and age, iGAS infection was associated with lower mortality risk (95% confidence interval (CI) of hazard ratio (HR) 0.204-0.746, p <  0.001). Morbidity analyses demonstrated that iGAS patients were more likely to develop renal failure. CONCLUSION: Critically ill patients with iGAS infection had a lower mortality risk but a higher degree of renal failure compared to similarly ill sepsis patients. emm1/T1 was found to be the most dominant serotype, and patients with emm1/T1 demonstrated more circulatory and renal failure than patients with other serotypes of iGAS.