Six-month quality-of-life and functional status of acute respiratory distress syndrome survivors compared to patients at risk: a population-based study.

INTRODUCTION: The long-term attributable burden related to acute respiratory distress syndrome (ARDS) is not fully investigated. The aim of this study is to evaluate the quality of life (QOL) and functional status at 6 months after hospitalization in patients at risk for ARDS who did and did not develop the syndrome. METHOD: This is a population-based prospective cohort study of adult patients from Olmsted County, Minnesota, with or at risk for ARDS hospitalized from October 2008 to July 2011. The primary outcomes were changes in QOL and functional status, measured through 12-Item Short Form Survey (SF-12) and Barthel Index (BI) respectively, from baseline to 6 months, compared between survivors who did and did not develop ARDS. RESULTS: Of 410 patients with or at risk for ARDS, 98 had baseline surveys collected and 67 responded to a 6-month survey (26 ARDS, 41 non-ARDS). Both ARDS and non-ARDS groups had lower physical component of SF-12 at baseline compared to general population (P < 0.001 for both). ARDS patients had poorer baseline functional status compared to non-ARDS (mean BI 80 ± 25 vs. 88 ± 22, P = 0.03). No significant differences were observed for the change between 6 months and baseline BI (delta 2.3 for ARDS vs. 2.0 for non-ARDS, P = 0.5), or mental (delta 2.7 vs. 2.4, P = 0.9) or physical (delta -3 vs. -3.3, P = 0.9) component of SF-12 between survivors with and without ARDS. CONCLUSION: In this population-based study, decreased QOL and functional status 6 months after hospitalization were largely explained by baseline condition, with similar recovery in survivors who did and did not develop ARDS.

Neuromuscular and neuropsychological assessments in survivors of acute respiratory distress syndrome: exploratory comparisons with an at-risk cohort.

BACKGROUND: Long-term studies of survivors of acute respiratory distress syndrome (ARDS) have reported neuromuscular, quality of life, and neuropsychological impairments. This study aims to determine if development of ARDS was associated with neuromuscular weakness and depression at 6-month following hospital discharge in a population-based cohort of patients at high risk for ARDS. METHODS: A validated lung injury prediction model prospectively identified adult patients at increased risk for ARDS admitted to Mayo Clinic between October 2008 and July 2011. Instruments for functional impairment [Overall Neuropathy Limitations Scale (ONLS)] and the presence of depressive symptoms (the Yale Single Question) were administered at baseline and at 6 months. RESULTS: Of 107 patients enrolled in the study, 98 (92 %) underwent baseline assessment. Of these, 83 (85 %) were admitted to intensive care, 41 (42 %) developed ARDS, and 67 (68 %) completed assessment at 6 months. Patients with ARDS had longer intensive care and hospital length of stay (7.9 vs. 3.1 days, p = 0.005 and 19.5 vs. 10.6 days, p = 0.004, respectively). There was no difference in reported functional impairment at 6 months from baseline in the ARDS group compared to the non-ARDS group-mean ONLS Total Score 2.95 versus 2.07 p = 0.09 and 3.0 versus 2.1 p = 027, respectively. There was also no difference in the prevalence of depression at 6 months between the ARDS and non-ARDS group (21.9 vs. 30.7 % p = 0.41). CONCLUSIONS: In this single-center population-based cohort study, survivors of ARDS in the community had similar reported functional impairment and depression prevalence compared to an at-risk cohort that did not develop ARDS.

Trends in the use of renal replacement therapy modality in intensive care unit: a 7 year study.

BACKGROUND: The use of renal replacement therapy (RRT) modality in the intensive care unit (ICU) depends primarily on provider preference and hospital resource. This study aims to describe the prevalence of RRT use and the trends in RRT modality use in the ICU over the past 7 years. METHODS: All ICU admissions, including medical, cardiac, and surgical ICUs from 1 January 2007 to 31 December 2013, were included in this study. RRT use was defined as the use of intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT) within a given ICU day. The RRT use was reported as the proportion of ICU days on each RRT modality divided by the total ICU days with RRT usage. RESULTS: Over the course of this study (72,005 ICU admissions), 272,271 ICU days were generated. RRTs were used in 4110 ICU admissions (5.7%) and on 21,159 ICU days (7.8%). RRT use was 10,402 (49%) for IHD, and 10,954 (52%) for CRRT. The trend of IHD and CRRT use did not change from year 2007 to 2013. On ICU days with RRT, the choice of RRT modality was associated with the number of vasopressor use (p < 0.001). CRRT was more preferred on the ICU days with the increasing number of vasopressor use. CONCLUSIONS: RRTs were used in about 6% of ICU admission. The use of IHD and CRRT was similar and did not change over 7 years. The choice of RRT modality mainly depended on the number of vasopressors used on ICU days with RRT.

The role of potentially preventable hospital exposures in the development of acute respiratory distress syndrome: a population-based study.

OBJECTIVE: Acute respiratory distress syndrome is a common complication of critical illness, with high mortality and limited treatment options. Preliminary studies suggest that potentially preventable hospital exposures contribute to acute respiratory distress syndrome development. We aimed to determine the association between specific hospital exposures and the rate of acute respiratory distress syndrome development among at-risk patients. DESIGN: Population-based, nested, Matched case-control study. PATIENTS: Consecutive adults who developed acute respiratory distress syndrome from January 2001 through December 2010 during their hospital stay (cases) were matched to similar-risk patients without acute respiratory distress syndrome (controls). They were matched for 6 baseline characteristics. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Trained investigators blinded to outcome of interest reviewed medical records for evidence of specific exposures, including medical and surgical adverse events, inadequate empirical antimicrobial treatment, hospital-acquired aspiration, injurious mechanical ventilation, transfusion, and fluid and medication administration. Conditional logistic regression was used to calculate the risk associated with individual exposures. During the 10-year period, 414 patients with hospital-acquired acute respiratory distress syndrome were identified and matched to 414 at-risk, acute respiratory distress syndrome-free controls. Adverse events were highly associated with acute respiratory distress syndrome development (odds ratio, 6.2; 95% CI, 4.0-9.7), as were inadequate antimicrobial therapy, mechanical ventilation with injurious tidal volumes, hospital-acquired aspiration, and volume of blood products transfused and fluids administered. Exposure to antiplatelet agents during the at-risk period was associated with a decreased risk of acute respiratory distress syndrome. Rate of adverse hospital exposures and prevalence of acute respiratory distress syndrome decreased during the study period. CONCLUSIONS: Prevention of adverse hospital exposures in at-risk patients may limit the development of acute respiratory distress syndrome.

Actual versus ideal body weight for acute kidney injury diagnosis and classification in critically ill patients.

BACKGROUND: In the current acute kidney injury (AKI) definition, the urine output (UO) criterion does not specify which body weights (BW), i.e. actual (ABW) versus ideal (IBW), should be used to diagnose and stage AKI, leading to heterogeneity across research studies. METHODS: This is a single center, retrospective, observational study conducted at a tertiary referral hospital. All adult patients who were admitted to intensive care units (ICUs) at our institution for a minimum of 6 continuous hours between January and March 2010 and had a urinary catheter for hourly urine output monitoring were eligible for this study. Patients' AKI stages, based on UO criterion, were assessed by calculating each milliliter of urine per kilogram per hour, using ABW versus IBW. RESULTS: A total of 493 ICU patients were included in the analysis. The median ABW and IBW were 82 (IQR 68-96) and 70 (IQR 60-77) kg, respectively. Using the IBW criterion, 154 patients (31.2%) were diagnosed with AKI, while 204 (41.4%) were diagnosed using the ABW measurement (P-value<.01). Patients who had AKI regardless of BW type had an adjusted odds ratio of 1.76 (95% CI 1.05-2.95) for 90-day mortality, whereas patients who had AKI according to ABW but not IBW had no significant increase in the risk of 90-day mortality, adjusted OR 0.76; (95% CI 0.25-1.91), compared to patients who had no AKI. CONCLUSIONS: Using ABW to diagnose and stage AKI by UO criterion is more sensitive and less specific than IBW. Based on the application of the definition, different BW types could be utilized.

Predictors of teriparatide treatment failure in patients with low bone mass.

INTRODUCTION: While teriparatide is the only skeletal anabolic agent approved in the United States, treatment failure is a major concern which complicates its clinical utility. We sought to identify factors that predict response failure in patients with low bone mass. METHOD: We performed a retrospective study of adults with osteopenia or osteoporosis (T-scores < - 1.0 and - 2.5 SD below normal, respectively, at the total hip or lumbar spine) treated with teriparatide at the Mayo Clinic (Rochester, Minnesota) between November 2002-December 2012. Trained study investigators blinded to patient outcomes collected electronic medical record data. Potential response failure predictors were identified using univariate analysis. Multivariable logistic regression modeling was used to identify independent predictors of treatment failure based on either osteoporotic fragility fracture or BMD response. RESULTS: During the 10-year period, 494 patients received teriparatide treatment and met eligibility criteria. Thirty-five patients had osteoporotic fractures, while 172 did not achieve a ≥ 3% BMD increase. Among predictors as defined by BMD change, both prior bisphosphonate treatment [odds ratio (95% confidence interval), 1.50 (1.01-2.24)] and vitamin D therapy [1.50 (1.01-2.22)] were significantly (P < 0.05) associated with teriparatide treatment failure. By contrast, no predictors were associated with treatment failure when fracture was the endpoint. CONCLUSION: These data suggest that prior bisphosphonate or vitamin D exposure may predict response failure to teriparatide therapy. Although these findings may, in part, reflect increased severity or longer duration of disease, this knowledge should help guide clinicians and patients when therapy choices are made.

Adverse in-hospital events are associated with increased in-hospital mortality and length of stay in patients with or at risk of acute respiratory distress syndrome.

OBJECTIVE: To explore the effect of various adverse hospital events on short- and long-term outcomes in a cohort of acutely ill hospitalized patients. PATIENTS AND METHODS: In a secondary analysis of a retrospective cohort of acutely ill hospitalized patients with sepsis, shock, or pneumonia or undergoing high-risk surgery who were at risk for or had developed acute respiratory distress syndrome between 2001 and 2010, the effects of potentially preventable hospital exposures and adverse events (AEs) on in-hospital and intensive care unit (ICU) mortality, length of stay, and long-term survival were analyzed. Adverse effects chosen for inclusion were inadequate empiric antimicrobial coverage, hospital-acquired aspiration, medical or surgical misadventure, inappropriate blood product transfusion, and injurious tidal volume while on mechanical ventilation. RESULTS: In 828 patients analyzed, the distribution of 0, 1, 2, and 3 or more cumulative AEs was 521 (63%), 126 (15%), 135 (16%), and 46 (6%) patients, respectively. The adjusted odds ratios (95% CI) for in-hospital mortality in patients who had 1, 2, and 3 or more AEs were 0.9 (0.5-1.7), 0.9 (0.5-1.6), and 1.4 (0.6-3.3), respectively. One AE increased the length of stay, difference between means (95% CI), in the hospital by 8.7 (3.8-13.7) days and in the ICU by 2.4 (0.6-4.2) days. CONCLUSION: Potentially preventable hospital exposure to AEs is associated with prolonged ICU and hospital lengths of stay. Implementation of effective patient safety interventions is of utmost priority in acute care hospitals.

Outcome of adverse events and medical errors in the intensive care unit: a systematic review and meta-analysis.

Adverse events and medical errors (AEs/MEs) are more likely to occur in the intensive care unit (ICU). Information about the incidence and outcomes of such events is conflicting. A systematic review and meta-analysis were conducted to examine the effects of MEs/AEs on mortality and hospital and ICU lengths of stay among ICU patients. Potentially eligible studies were identified from 4 major databases. Of 902 studies screened, 12 met the inclusion criteria, 10 of which are included in the quantitative analysis. Patients with 1 or more MEs/AEs (vs no MEs/AEs) had a nonsignificant increase in mortality (odds ratio = 1.5; 95% confidence interval [CI] = 0.98-2.14) but significantly longer hospital and ICU stays; the mean difference (95% CI) was 8.9 (3.3-14.7) days for hospital stay and 6.8 (0.2-13.4) days for ICU. The ICU environment is associated with a substantial incidence of MEs/AEs, and patients with MEs/AEs have worse outcomes than those with no MEs/AEs.